Failure to Provide Accessible and Sufficient Hydration for Residents
Penalty
Summary
The facility failed to ensure that residents had access to water in their rooms, as required to maintain adequate hydration. Observations and interviews revealed that four residents did not have water readily available or accessible. One resident with cerebral palsy, acute kidney failure, diabetes, and hypertension was found unable to reach his water pitcher, which was placed out of reach on a table at the foot of his bed. Another resident with heart failure and cognitive communication deficit reported that his water was not refreshed for several days, was hot, and lacked ice, requiring him to get his own ice. A third resident with cerebral infarction and moderate cognitive deficit stated that he was not offered ice water and typically had to get it himself, sometimes finding no ice available. The fourth resident, who had a right femur fracture and was cognitively intact, reported that her water pitcher was only filled upon request and that she usually poured water from meal cups into her pitcher. Staff interviews confirmed that there were complaints from residents about not receiving ice or water, and that the responsibility for passing water was not consistently fulfilled. The Director of Nurses stated that staff should be passing ice water at the beginning of each shift, with meals, and as needed. However, the facility was unable to provide a policy regarding ensuring water availability in resident rooms, further contributing to the deficiency.