Failure to Monitor Fluid Intake for At-Risk Resident
Penalty
Summary
Facility staff failed to monitor and document fluid intake for a resident who was at risk for dehydration. The resident, who had diagnoses including hypernatremia, acute kidney failure, and Alzheimer's disease, required partial to moderate assistance and was identified in the care plan as being at risk for dehydration. The care plan specified monitoring for signs and symptoms of dehydration and encouraging or assisting with fluid intake. However, documentation for the months reviewed showed no entries for fluid intake, and staff interviews confirmed that there was no active task or system in place to record the resident's fluid consumption during this period. The resident was unable to eat or drink independently and required total assistance from staff, who reported that although fluids were offered, the resident often refused them. Despite this, there was no documentation of fluid intake, and the facility's policy required intake and output monitoring for residents at risk of dehydration. The deficiency resulted in the resident being readmitted to a general acute care hospital with severe dehydration and hypernatremia, as documented in the hospital's history and physical report.