Failure to Monitor and Document Hydration Therapy per Physician Orders
Penalty
Summary
The facility failed to ensure that a resident with severe cognitive impairment and multiple medical conditions, including heart and kidney disease, was consistently monitored and received adequate hydration fluids as ordered by the physician. The resident was observed with an infusion bag for subcutaneous fluids that lacked essential labeling, such as start time, infusion rate, and staff initials. The infusion was administered without a pump to indicate the rate, and there was no documentation on the bag or dressing to verify when the infusion began or who initiated it. Staff interviews revealed uncertainty about the infusion's start time and rate, and the dial flow device was set below the ordered rate. The resident continued to receive fluids at a slower rate than prescribed for two days without a physician's order to do so. Review of the resident's medical record confirmed a physician's order for two liters of sodium chloride to be infused subcutaneously at 70 ml/hr for one day. However, staff were unable to confirm compliance with this order due to missing documentation and improper labeling. The Director of Nursing Services acknowledged that nursing staff are expected to document and follow physician orders, but this was not done in this case. The lack of monitoring, documentation, and adherence to physician orders placed the resident at risk for complications related to inadequate hydration.