Failure to Monitor and Document Fluid Restriction for Dialysis Resident
Penalty
Summary
The facility failed to monitor and document the daily fluid intake for a resident with end stage renal disease (ESRD) and heart failure who was on dialysis and had a physician-ordered fluid restriction of 1000cc per day. The resident's care plan specified the distribution of fluids across nursing shifts and meals, and the order included instructions that no water pitcher be kept at the bedside. However, review of the Medication Administration Record (MAR) and interviews with nursing staff revealed that there was no documentation of the resident's actual fluid intake for any shift over a two-week period. The MAR only allowed staff to acknowledge the fluid restriction order, not to record intake amounts, and there was no alternative location for this documentation. Multiple licensed nursing staff confirmed that fluid intake amounts were not recorded as required, and the resident's chart lacked any notes indicating intake for the period in question. Staff acknowledged that without accurate and complete intake records, it was not possible to ensure the resident's fluid intake remained within the prescribed limits. The Director of Nursing also confirmed that monitoring and documentation of fluid intake should have occurred according to policy and physician orders. Review of facility policy indicated that special care monitoring, including fluid restriction, is required for residents on dialysis.