Failure to Maintain Nutrition and Hydration Status for Two Residents
Penalty
Summary
The facility failed to maintain the nutrition and hydration status of two residents by not following established protocols for monitoring and responding to significant changes in weight and fluid intake. For one resident with chronic kidney disease and dysphagia, there was a significant weight loss of over 10% between two recorded weights. Despite facility policy requiring re-weighing and notification of the Registered Dietician (RD) and physician for such discrepancies, the medical record did not show that these steps were taken. The RD acknowledged that the weight discrepancy may have been overlooked due to the resident moving floors, but confirmed that follow-up was still required. For another resident with heart failure and chronic respiratory failure, the facility did not adhere to a physician's order for a 1000 ml fluid restriction per 24 hours. Documentation showed that the resident consistently received more fluids than ordered, with daily intakes ranging from 1,100 to 1,200 ml. Facility policy required that any non-compliance with fluid restrictions or changes in the resident's condition be recorded and reported to the physician, but there was no evidence in the medical record that the physician was notified of the excess fluid intake. Interviews with staff confirmed that the established protocols for monitoring and reporting significant weight changes and fluid restriction compliance were not followed. The failures included not validating significant weight loss with a re-weigh and not notifying the appropriate clinical staff, as well as not documenting or reporting fluid intake above the prescribed limit to the physician.