Failure to Accurately Monitor Nutrition and Fluid Restrictions
Penalty
Summary
The facility failed to accurately monitor and manage the nutritional status and fluid intake of three residents, resulting in deficiencies related to nutrition and hydration. For one resident with COPD, diabetes, and dementia, multiple observations showed the resident was unable to self-feed effectively, consuming minimal portions of meals, yet meal intake records inaccurately reflected higher consumption. Staff interviews confirmed that meal intake documentation included fluids and did not accurately represent food intake, which did not meet facility expectations. Another resident with COPD, diabetes, and atrial fibrillation was on a fluid restriction, but there was a lack of clear communication between nursing and dietary staff regarding the specific amount of fluids to be provided by dietary. The dietary manager was unaware of the exact fluid allocation and only provided a small amount of juice, while the medication administration record did not account for fluids provided by dietary. Staff acknowledged that the fluid restriction was not properly communicated or documented. A third resident with end stage renal disease, diabetes, and atrial fibrillation was also on a fluid restriction, but was observed with unrestricted fluids at bedside and managed their own intake, contrary to provider orders. The dietary manager was unaware of the fluid restriction, and staff confirmed that the resident's fluid intake was not monitored if they had access to fluids independently. The care plan specified fluid limits, but the resident did not comply, and monitoring was not enforced.