Failure to Monitor and Document Fluid Restriction for Resident on Hemolytic Treatment
Penalty
Summary
A resident with end stage renal disease, congestive heart failure, and anemia was admitted to the facility and required hemolytic treatment. The resident had a physician's order for hemolytic treatment three times per week and a fluid restriction of 1000 cc per 24 hours, as recommended by a nephrologist due to episodes of hypotension during treatment. The care plan and dietary instructions reflected this restriction, with specific fluid amounts allocated for meals and medication administration. Despite these orders, a review of the clinical records, including nursing notes, MAR, and TAR, revealed that there was no documentation or tally of the resident's daily fluid intake from the time the fluid restriction order was implemented. Interviews with nursing staff showed confusion regarding responsibility for tracking fluid intake, with some staff believing it was the responsibility of licensed nurses and others indicating it was a shared responsibility. The fluid restriction order was not visible on the MAR, and staff acknowledged that the order had not been properly activated to prompt documentation. The resident was not aware of the fluid restriction until two days prior to the survey, and reported consuming both facility-provided and outside food and fluids without tracking intake. The dietician confirmed that nursing staff were expected to maintain intake records for residents on fluid restriction, but the order may not have been activated in the system. The facility's policy required nursing personnel to document fluid intake, but this was not done for the resident in question. The facility was unable to demonstrate how the total fluid intake was tracked or maintained for the resident as required by the physician's order.