Failure to Follow and Document Fluid Restriction Orders for Dialysis Residents
Penalty
Summary
The facility failed to ensure that physician orders for fluid restrictions were followed and accurately documented for two residents with end stage renal disease (ESRD) and congestive heart failure (CHF) who were receiving hemodialysis. Both residents had care plans and physician orders specifying a daily fluid restriction of 1500 ml, with detailed allocations for nursing and dietary staff across different shifts and meals. However, clinical record reviews for both residents did not show evidence that their fluid intake was being accurately tracked or documented in accordance with these orders. An interview with a licensed employee confirmed that the facility did not accurately follow or document the daily fluid consumption for these residents as prescribed. The deficiency was cited under regulations related to clinical records and nursing services, with previous citations noted for the same areas.