Failure to Follow Physician-Ordered Fluid Restriction
Penalty
Summary
A deficiency occurred when the facility failed to follow a physician-ordered fluid restriction for a resident diagnosed with COPD, vascular dementia, and congestive heart failure. The physician's order specified a 2,000 cc fluid restriction per 24 hours, with dietary and nursing staff assigned specific amounts to provide at each meal and shift. The care plan identified the resident as being at risk for nutrition and hydration issues related to CHF, with interventions to monitor for dehydration and fluid overload and to encourage adequate fluid intake. On observation, the resident was served a breakfast tray containing a total of 1,440 cc of fluids (480 cc each of pop, orange juice, and hot tea), which exceeded the amount allotted for that meal. A CNA who served the fluids stated she was unaware of the resident's fluid restriction. Review of facility policy indicated that licensed nurses are responsible for recording and verifying fluid intake for residents on fluid restrictions, but this process was not followed, resulting in the resident receiving more fluids than ordered.