Failure to Monitor and Document Fluid Restriction for Resident with Heart Failure
Penalty
Summary
The facility failed to provide adequate nutritional and hydration care for a male resident with chronic diastolic heart failure who was under a physician-ordered fluid restriction of 1500mL per day, divided between nursing and dietary services. Despite clear care plan interventions and physician orders specifying the fluid restriction and the need to document non-compliance and notify the physician, there was no documentation of the resident's fluid intake in the progress notes for several months. During observation, a CNA provided the resident with two glasses of water totaling 480mL at one meal, and staff interviews revealed inconsistent awareness and understanding of the fluid restriction details. Some CNAs and nurses were unsure of the specific limits or how to track cumulative intake, and there was no consistent communication of intake amounts during shift reports. The resident reported that staff reminded him to limit his intake but did not specifically monitor or ask about the amount he consumed. Staff interviews further indicated that fluid intake was not systematically tracked or communicated across shifts, and there was uncertainty among staff about how to determine if the resident exceeded his daily fluid limit. The facility's policy required care to be provided according to professional standards and the resident's care plan, but these standards were not met in the monitoring and documentation of the resident's fluid intake.