Failure to Implement and Monitor Fluid Restriction for Resident
Penalty
Summary
A resident with a history of chronic kidney disease, type 2 diabetes mellitus, and multiple skin conditions was recently readmitted to the facility following surgery and an infection requiring antibiotic therapy. The resident reported having been on a fluid restriction while hospitalized, but upon return to the facility, no such restriction was enforced. Observation revealed a large cup of water at the bedside, and the resident confirmed she was not on a fluid restriction since her return. Record review showed that the resident's care plan included a regular no added salt thin liquid diet with an 1800 milliliter fluid restriction. However, there were no physician orders or documentation regarding fluid intake or restriction in the resident's record. Facility policy required specific instructions and monitoring for fluid restrictions, including removal of water pitchers and documentation of intake, but these procedures were not followed for this resident.