Failure to Implement Physician-Ordered Fluid Restriction for Dialysis Resident
Penalty
Summary
Facility staff failed to implement a physician-ordered fluid restriction for a resident dependent on renal dialysis. The resident, who had end stage renal disease and moderately impaired cognitive skills, was admitted with a fluid restriction order of 1000ml per day, divided between dietary and nursing. Despite this order being placed on 5/19/2025, the restriction was not initiated or communicated to dietary staff until 6/4/2025. During this period, the resident continued to receive meals and fluids without any restriction, as evidenced by observations and review of dietary tray cards, which did not reflect the fluid restriction order. Interviews with nursing and dietary staff revealed a lack of awareness and communication regarding the fluid restriction order. The order was not activated in the resident's electronic chart, resulting in both nursing and dietary departments failing to enforce the restriction. The facility's policies required that fluid restrictions for dialysis residents be implemented as ordered and reflected on dietary records, but these procedures were not followed, leading to the resident not receiving the prescribed care.