Failure to Monitor and Document Fluid Intake Leads to Resident Dehydration and Hospitalization
Penalty
Summary
The facility failed to monitor and document the fluid intake of a dependent resident who required one-to-one supervision during meals, and did not assess for signs and symptoms of dehydration. The resident, who had multiple diagnoses including dementia, diabetes, and a history of cerebral infarction, was at risk for fluid imbalance and required assistance with eating and drinking due to cognitive and visual impairments. Despite care plan interventions that included encouraging fluid intake and monitoring for dehydration, there was no documentation of the resident's fluid intake in the electronic charting system, and staff interviews confirmed that the system did not provide a place to record fluid intake. Observations revealed that water was not consistently provided during meals, and staff did not always encourage or assist residents with drinking fluids. Staff interviews indicated that the resident needed significant assistance with feeding and drinking, but the amount of fluid consumed was not tracked or documented. The facility's own assessment and job descriptions required monitoring and recording of intake, but this was not implemented in practice. The dietician and acting Director of Nursing were unaware that fluid intake was not being documented, and no facility policy on meal and fluid intake documentation was provided for review. As a result of these failures, the resident experienced a significant decline in condition, presenting with lethargy and abnormal vital signs, and was emergently transferred to the hospital. Hospital records indicated severe hypernatremia and acute kidney injury, suspected to be secondary to dehydration, requiring intravenous fluids and antibiotics. The resident was hospitalized for five days and later died in the facility. The lack of fluid intake monitoring and documentation, combined with insufficient assessment for dehydration, directly contributed to the resident's adverse outcome.