Failure to Communicate Hydration Restrictions Leads to Care Plan Deviation
Penalty
Summary
Staff failed to follow the care plan regarding hydration needs for a resident with a history of stroke, hemiplegia, and dysphagia. The resident was observed receiving medications with pudding and water through a straw, despite care plan instructions specifying mildly thickened liquids with meals, thin liquids in the room only after oral care, and no use of straws as per speech therapy recommendations. The certified medication aide administering the medication was unfamiliar with the resident's specific needs, and the water mug in the resident's room contained a straw, contrary to the care plan. Interviews with dietary and nursing staff revealed that the restriction on straw use was documented in the care plan but was not transferred to the Kardex, the tool used by front-line caregivers to access residents' care needs. Both the CNA and RN confirmed reliance on the Kardex for such information, and the DON was unaware of the no-straw requirement. The facility's policy required care plans to reflect current care needs and ensure appropriate care and services, but the failure to update the Kardex led to staff not being informed of the resident's hydration restrictions.