Failure to Accurately Monitor Fluid Intake and Address Significant Weight Loss
Penalty
Summary
Facility staff failed to consistently and accurately monitor, document, and calculate fluid intake for a resident with end stage renal disease who was on a physician-ordered 1500 ml/day fluid restriction. The care plan required staff to record all food and fluid intake, with dietary and nursing staff responsible for providing and documenting specific fluid amounts per meal and shift. However, over a 14-day review period, staff did not consistently document fluid intake for all meals and did not accurately calculate the resident's 24-hour fluid intake on 14 of 15 days reviewed. In several instances, the documented totals did not match the actual intake, and some meal intakes were missing or not recorded at all. The administrator confirmed that the fluid intake records were incomplete and inaccurate, attributing the issue in part to confusing order entry. Additionally, the facility failed to identify significant weight loss and implement or evaluate nutritional interventions for another resident who was severely cognitively impaired and prescribed a controlled carbohydrate diet. Despite a documented weight loss of 14.5% over several months, staff were unaware of the weight loss and had not made a referral to the Registered Dietitian or implemented further interventions. The resident's care plan stated there should be no unplanned significant weight changes, and the nutritional evaluation had previously noted weight stability. However, upon review, both the RN Unit Manager and the Director of Nursing Services confirmed the weight loss and the lack of additional interventions. These deficiencies were identified through observation, interview, and record review, and were found to place residents at risk for continued weight loss, malnutrition, fluid volume overload, and other medical complications. The facility did not have an effective system in place to ensure accurate monitoring and documentation of fluid and nutritional intake, nor did it ensure timely identification and response to significant changes in residents' nutritional status.