Failure to Maintain Accessible Hydration for At-Risk Resident
Penalty
Summary
A resident with multiple complex medical conditions, including Alzheimer's disease, dementia, diabetes, chronic kidney disease, and a history of falls, was identified as being at risk for dehydration. Her care plan specifically required that water be maintained at her bedside at all times to support adequate hydration, especially given her use of diuretic medication and potential for fluid imbalance. During an observation, it was noted that the resident did not have any water or beverage available in her room, and there was no evidence of a Styrofoam cup or other drinking vessel as provided to other residents. A CNA confirmed that she had not provided water to the resident that morning and could not locate a cup in the room, suggesting it may have been discarded by housekeeping, although this was not the case in other rooms. On a subsequent observation, the resident was found to have a Styrofoam cup with water, but it was placed on an overbed table near the entry door, out of the resident's reach. Another CNA confirmed that the placement of the table and cup made it inaccessible to the resident, preventing her from obtaining a drink when needed. These findings demonstrate that the facility failed to ensure the resident had water maintained at her bedside and within reach, as required by her care plan.