Failure to Maintain Adequate Hydration and Monitoring for a Dependent Resident
Penalty
Summary
Facility staff failed to maintain adequate hydration for a resident who was dependent on staff for care. Upon admission, the resident had hospital orders for labs to be drawn in three days, but the facility delayed the first lab draw to eight days after admission and then scheduled subsequent labs at irregular intervals. The resident was placed on a 1500 ml fluid restriction, with daily weights ordered and documented. Despite clear instructions in the hospital discharge summary and care plan to notify the cardiology physician if the resident experienced a significant weight gain or worsening edema, there is no evidence that the cardiologist was ever contacted, even as the resident's weight increased by over 8 pounds, and symptoms of edema and shortness of breath developed. Instead, the facility physician made four medication changes to manage fluid overload symptoms. Review of intake and output records revealed that the resident rarely received the full amount of fluids allowed by the restriction, with only one day where the 1500 ml limit was met. Most days, the resident received significantly less, and there were days with no fluids recorded at all. Staff and family interviews indicated that the resident frequently complained of thirst and sought fluids from others, contradicting staff notes of noncompliance with the fluid restriction. The pattern of inadequate fluid provision, lack of timely physician notification, and insufficient monitoring contributed to the resident's worsening condition during the stay.