Failure to Provide Bedside Water Pitchers Results in Hydration Deficiency
Penalty
Summary
The facility failed to provide sufficient hydration to four residents when staff did not deliver bedside water pitchers for two consecutive days. Observations and interviews revealed that these residents, all of whom had medical conditions placing them at risk for dehydration, did not have water pitchers at their bedside tables during multiple checks. Instead, some residents only had partially filled cups or received water only at mealtimes, which was inconsistent with their care plans and facility policy. Resident records indicated that none of the affected residents were on fluid restrictions, and their care plans specifically identified them as being at risk for dehydration. For example, one resident with a history of urinary tract infection, type 2 diabetes, and high blood pressure, who was also prescribed a diuretic, had significantly reduced fluid intake on the days in question compared to her average intake for the month. Other residents with moderate cognitive impairment also lacked bedside water pitchers, and staff interviews confirmed that water pitchers should have been provided regardless of fluid restriction status. Staff interviews further clarified that the night shift was responsible for providing fresh water pitchers, and the day shift was expected to replace any missing pitchers. However, both nursing and CNA staff acknowledged that the absence of water pitchers could lead to adverse outcomes, and the facility's own hydration policy required staff to monitor hydration status and provide supportive measures, including supplemental fluids. The deficiency was directly linked to the failure of staff to ensure water pitchers were consistently available at residents' bedsides.