Failure to Ensure Adequate Nutrition and Hydration Resulting in Hospitalization
Penalty
Summary
Facility staff failed to adequately assess, monitor, and implement interventions to ensure that a resident's nutritional and hydration needs were met. The facility's own policy required staff to recognize and address each resident's nutritional and hydration needs, including regular assessments by a registered dietitian and daily documentation of intake by nursing staff. However, the registered dietitian was not notified of a dietary consult requested by the nurse practitioner after the resident was noted to have poor oral intake and refusal of nutritional supplements. The last nutritional assessment by the dietitian had been completed over a month prior to the incident, and no updated assessment or intervention was implemented in response to the resident's ongoing poor intake. The resident in question had multiple diagnoses, including coronary artery disease, dementia, COPD, and malnutrition, and was identified as being at risk for malnutrition and dehydration. Physician orders were in place for nutritional supplements, but nursing documentation showed repeated refusals of both meals and supplements over a two-week period. Fluid intake records indicated the resident consistently consumed significantly less than the required daily fluid needs, with intake often less than half of the minimum requirement. Despite these ongoing issues, there was no evidence of effective intervention or escalation to address the resident's declining intake. Laboratory results eventually revealed critically abnormal blood values, including elevated sodium, chloride, and BUN, indicating dehydration and electrolyte imbalance. Nursing staff notified the nurse practitioner, who ordered intravenous fluids, but attempts to administer them were unsuccessful due to the resident's resistance. The resident was subsequently transferred to the hospital, where they were admitted with diagnoses of hypernatremia and dehydration. The facility's failure to assess, monitor, and intervene resulted in actual harm to the resident.