Failure to Accurately Monitor and Document Fluid Intake for Resident on Fluid Restriction
Penalty
Summary
The facility failed to ensure accurate documentation and monitoring of a resident's fluid intake while the resident was on a fluid restriction. The resident, who had a history of congestive heart failure and kidney disease, was admitted following hospitalization for heart failure and septic shock, with hospital records indicating a fluid restriction order of 2000 mL per day. However, the facility's provider orders did not include this fluid restriction, although the care plan and Kardex referenced it. There was no clear guidance on how much fluid was to be provided per shift or how much was to be given with meal trays and between meals. Observations showed that the resident had access to a water pitcher and received oral nutrition supplements, but there was no consistent or accurate documentation of total fluid intake. Staff interviews revealed confusion regarding the process for monitoring and documenting fluid intake, with some staff estimating amounts consumed and others unsure of the specific orders or responsibilities. The kitchen staff was not provided with instructions regarding the fluid restriction, and the resident's medical record lacked documentation of shift-by-shift fluid intake reconciliation. The lack of clear provider orders, absence of specific instructions for staff, and failure to document and monitor fluid intake placed the resident at risk. The deficiency was identified through observation, interview, and record review, which confirmed that the facility did not maintain an accurate account of the resident's fluid intake as required for residents on fluid restrictions.