Failure to Provide Ordered Fluids for Hydration
Penalty
Summary
A resident with diagnoses including dementia, mild protein-calorie malnutrition, and aphasia was admitted to the facility and had physician orders and care plan directives to receive 360mL of fluid by mouth three times daily with medication pass and 360mL of fluid by mouth twice daily at snack times. Review of the resident's medical record, medication administration record (MAR), and electronic fluid intake flowsheets revealed that the resident did not consistently receive the ordered amounts of fluids on multiple dates. Documentation showed that the resident neither refused nor consumed the required fluids during several medication passes and snack times. Interviews with facility staff confirmed the deficiency. A CNA stated that fluid intake was monitored and documented during meals and snack times, while an LPN admitted to providing medications mixed with pudding but not offering the required 360mL of fluid with medication administration. The Director of Nursing confirmed that the resident did not receive the prescribed quantity of fluids each day, as required by the physician's orders and care plan.