Failure to Develop and Implement Resident-Centered Care Plan for Fluid Restriction
Penalty
Summary
The facility failed to develop a comprehensive, resident-centered care plan for a resident who had physician orders for fluid restriction. The resident was admitted with a history of edema, chronic heart failure, and chronic kidney disease, and was able to make medical decisions. Physician orders were documented for fluid restriction, initially set at 1.5 liters per day and later reduced to 1 liter per day, with specific instructions for dietary intake and the use of a condom catheter for intake and output monitoring. Despite these orders and the resident's changing clinical condition—including peripheral edema, abnormal lung sounds, weight gain, vesicles on the lower legs, and later respiratory distress—the facility did not create or update a care plan to address the fluid restriction or the use of the condom catheter. Multiple record reviews and staff interviews confirmed that no care plan was developed or revised to reflect the resident's needs or the physician's orders, even as the resident's condition worsened. The facility's own policy required person-centered care plans with measurable objectives and timetables to meet each resident's needs, and for care plans to be updated as conditions changed. However, the care plans for this resident were found to be non-existent or not specific and resident-centered, failing to address the physician-ordered interventions and the resident's evolving symptoms.