Failure to Provide Sufficient Fluids to Maintain Resident Hydration
Penalty
Summary
The facility failed to ensure that residents were consistently offered sufficient fluids to maintain proper hydration and health. One resident with diagnoses including Parkinson's, dementia, and muscle weakness was identified as having a high risk for dehydration, with a registered dietitian estimating daily fluid needs between 2040-2380 ml. However, the resident's diet orders only provided 1440 ml, and actual intake was significantly lower on several days prior to hospital transfer. The resident was admitted to the hospital with acute hypernatremia and dehydration, as confirmed by laboratory results and interviews with facility nursing leadership, who acknowledged the decreased fluid intake. Observations in multiple dining areas revealed that several residents did not have drinks provided during meals, and some reported being thirsty with empty cups. Staff interviews confirmed that water was not consistently passed out during meal times, and there was confusion about documentation of fluid intake. Resident Council meeting records also documented complaints about water not being provided. Despite staff re-education, observations continued to show that water was not reliably offered, and the facility's hydration policy requiring sufficient fluid intake was not followed.