Failure to Document Fluid Restriction and Administer Prescribed Medication for Dialysis Resident
Penalty
Summary
The facility failed to ensure that a resident with end stage renal disease and dependent on renal dialysis received care and services consistent with physician's orders and professional standards. Specifically, the resident had a physician's order for a 1000 ml daily fluid restriction, with detailed breakdowns for nursing and dietary fluid allowances, and required documentation of total fluid intake each shift. However, from 7/7/2025 to 7/17/2025, only nursing fluid intake was documented, and there was no evidence of total daily fluid intake being recorded. Staff interviews confirmed that intake and output were not documented, and the facility was unable to provide evidence that the fluid restriction was followed as ordered. Additionally, the resident had a physician's order for Sevelamer Carbonate 800 mg three times daily with meals to manage high blood phosphorus levels. On multiple dialysis days, the medication was not administered as ordered because the resident was absent from the facility for dialysis during scheduled administration times. The medication was not given after the resident returned, and there was no documentation that the provider was notified of the missed doses. Staff acknowledged the missed administrations and the lack of provider notification, and facility leadership could not provide evidence that the resident received the medication as ordered.