Failure to Implement and Document Physician-Ordered Fluid Restriction and Lab Test
Penalty
Summary
The facility failed to follow professional standards in implementing and documenting a physician-ordered fluid restriction and in completing a physician-ordered basic metabolic panel (BMP) lab test for a resident diagnosed with hyponatremia. The resident, who had moderate cognitive impairment and multiple diagnoses including hypertension, hypo-osmolality, and dementia, was ordered to have a daily fluid restriction of 40 ounces (1200 cc) and a BMP lab test. Review of the resident's medical record showed inconsistent and incomplete documentation of fluid intake, with daily totals often below the prescribed limit, and no evidence that all sources of fluid, such as supplements and Jello, were consistently counted or recorded. Observations revealed that the resident had access to fluids in her room, including a water pitcher and juice, despite the fluid restriction order. Staff interviews indicated confusion and lack of clarity regarding the fluid restriction order, with some staff unaware of the correct restriction amount and others not counting certain fluids, such as Jello, toward the daily total. Documentation responsibilities were inconsistently assigned between nursing, dietary, and activities staff, leading to gaps in tracking the resident's actual fluid intake. Additionally, there was no designated task in the electronic medical record for documenting the amount of supplement consumed, and CNA documentation of fluid intake was inconsistent or missing on some days. The facility also failed to complete the physician-ordered BMP lab test for the resident as scheduled. The director of nursing confirmed that the lab was not completed as ordered. Furthermore, the facility was unable to provide a fluid restriction policy when requested by surveyors, and there was no documentation verifying communication of the fluid restriction during nurse shift reports. These failures resulted in the facility not meeting professional standards of quality in the care of the resident.