Failure to Monitor and Intervene for Resident's Decreased Intake Resulting in Hospitalization for Dehydration
Penalty
Summary
Facility staff failed to adequately monitor and respond to a resident's hydration and nutrition status, resulting in a significant change in the resident's condition. The resident, who was dependent on staff for feeding, experienced a marked decrease in oral intake over several days, with documentation showing missed meals and reduced intake from 3/1/25 to 3/5/25. Despite these changes, there was no evidence that the resident was assessed by the dietitian during this period, nor was there an updated nutritional assessment since 9/9/24. The resident's condition deteriorated to the point where they became nonverbal and unresponsive, requiring supplemental oxygen and an attempted IV, which could not be established by facility staff. The resident was subsequently transferred to a local hospital, where they were diagnosed and treated for dehydration. Hospital records confirmed that facility staff reported decreased oral intake prior to the transfer. Interviews with the facility dietitian revealed that reduced intake should have triggered an alert and a reassessment, but this did not occur. The Director of Nursing was informed of the failure to monitor the resident's intake and implement interventions to prevent dehydration.