Failure to Consistently Monitor and Document Fluid Restriction for Dialysis Resident
Penalty
Summary
The facility failed to ensure consistent monitoring and documentation of intake and output for a resident with end stage renal disease who was on a physician-ordered fluid restriction of 1,000 ml per day and received dialysis. The care plan and physician's orders specified the fluid restriction, but staff did not consistently document the resident's intake and output, and the resident did not meet the prescribed fluid restriction on multiple occasions across several months. The intake and output records for March, April, and early May showed repeated failures in both documentation and adherence to the fluid restriction, with staff not recording intake and output as required. Interviews with nurse aides revealed that intake and output were to be documented electronically, but there were lapses in documentation. The regional clinical support LPN and the DNS both acknowledged awareness of non-compliance with the intake and output policy, despite prior education provided to staff. Neither the DNS nor the LPN was aware that the resident was not meeting the fluid restriction as ordered. Additionally, the physician's orders did not initially specify the breakdown of fluid allocation between nursing and dietary services until after surveyor inquiry. Further, the dialysis center RN was not notified by the facility about the inconsistent monitoring of intake and output, and both the attending physician and APRN were unaware that the physician's order for fluid restriction was not being followed. The facility's policy required accurate and timely documentation of fluid intake, but this was not consistently performed, leading to the deficiency in care for the resident requiring specialized dialysis services.