Failure to Provide Appropriate Fluids and Meal Assistance
Penalty
Summary
The facility failed to ensure that residents on the memory care unit had consistent access to appropriate fluids and adequate assistance with meals, as evidenced by multiple observations and staff interviews. One resident, who was ordered to receive mildly thickened fluids, was observed without any fluids in her room and later with a pitcher of regular, unthickened water, contrary to her care plan. Staff interviews revealed a lack of awareness regarding which residents were at risk of dehydration and inconsistent practices regarding the provision of water pitchers. Additionally, staff reported that water pitchers sometimes disappeared and that some residents did not have access to drinks unless they specifically requested them. Another resident experienced a significant weight loss of 6.5% in one month and was observed multiple times without access to fluids or assistance with meals. Her breakfast tray was left untouched as she remained asleep, and staff did not assist her with eating. Staff interviews indicated that residents on the memory care unit were not provided drinks at the bedside due to concerns about other residents consuming them and infection control. Documentation showed that the resident's hydration status was poor enough that IV fluids were considered, and staff had not coordinated with dietary services to address her preferences or needs. The facility did not provide a policy on maintaining resident hydration when requested by the surveyor.