Failure to Provide Adequate Hydration and Monitor Weight Loss
Penalty
Summary
The facility failed to ensure proper hydration for three residents and did not maintain the usual body weight for another resident, as required by facility policy and each resident's care plan. Multiple observations revealed that three residents did not have fluids available at their bedside on several occasions, despite care plans specifying the need for monitoring and encouraging fluid intake. Staff interviews confirmed the absence of fluids and acknowledged the importance of having fluids accessible to prevent dehydration, with some residents displaying signs such as chapped lips and expressing thirst. One resident with a history of urinary tract infection and an indwelling catheter was observed without fluids at bedside, and staff noted dark urine in the collection bag. Another resident, who was on diuretics and required assistance with fluid intake, reported waiting for hours for a water refill and feeling frustrated by unmet needs. Staff confirmed the lack of fluids and recognized the associated risks, as outlined in the residents' care plans and the facility's hydration policy. Additionally, the facility did not consistently monitor and document the weight of a resident with multiple diagnoses, including diabetes, anemia, and mild malnutrition, who experienced significant weight loss over several months. Weight records were missing for three months, and there was no documentation of refusal to be weighed or care plan updates reflecting such refusals. Staff interviews confirmed that weights should have been taken and documented monthly, and that refusals should have been recorded and communicated to the interdisciplinary team, but these actions were not completed as required by facility policy.