Failure to Document and Implement Physician-Ordered Fluid Restriction
Penalty
Summary
A deficiency occurred when the facility failed to complete a physician's order for a resident with cirrhosis of the liver, diastolic congestive heart failure, and obesity, who was on a restricted fluid intake. The resident was admitted with a hospital discharge note and a current physician's order specifying a 1500 ml fluid restriction. However, the clinical record lacked documentation of fluid intake and did not include a care plan addressing the fluid restriction. During an interview, the ADON stated that the fluid restriction was considered a dietary recommendation rather than a direct order, leading to the order not being tracked or implemented as required. Facility policy on fluid-restriction diets was available but not followed in this case.