Failure to Assess and Address Resident's Nutrition and Hydration Needs
Penalty
Summary
The facility failed to evaluate and address the nutrition and hydration requirements for one resident, resulting in a deficiency. Despite facility policies requiring comprehensive nutritional and hydration assessments by the dietitian upon admission and as needed, there was no documented evidence that such an assessment was completed for the resident after admission. The resident, who had diagnoses including dementia and COPD, was prescribed Lasix, a diuretic known to increase the risk of dehydration. The resident's fluid intake was significantly below recommended levels for several days, with recorded intakes of 240 cc, 660 cc, and 600 cc over three consecutive days. There was no documentation that nursing aides notified nursing staff of the low fluid intake, as required by policy. Laboratory results during this period showed elevated BUN and creatinine levels, which can indicate dehydration. Despite these findings and the resident's ongoing use of Lasix, there was no evidence of intake and output monitoring or nutritional interventions being established. The resident experienced a change in mental status, leading to a hospital transfer where a diagnosis of acute kidney injury with dehydration was made, and Lasix was held while IV fluids were initiated. The Director of Nursing confirmed that a comprehensive nutritional and hydration assessment was not completed and that appropriate interventions were not implemented.