Failure to Assess and Manage Dehydration in a High-Risk Resident
Penalty
Summary
Facility staff failed to ensure that care and services provided to a resident met accepted professional standards, specifically in the assessment and management of dehydration. The resident, who had a complex medical history including Ogilvie's Syndrome, dementia, chronic kidney disease, and a urostomy, was admitted following a hospitalization for gastrointestinal issues. Upon admission, the resident was severely cognitively impaired, required maximum assistance with activities of daily living, and was dependent on staff for feeding and hydration. Despite these vulnerabilities, staff did not consistently monitor or document the resident's fluid intake, and there was no evidence that poor oral intake or declining urostomy output was communicated to the medical provider. Throughout the resident's stay, multiple staff members, including CNAs and nurses, reported that the resident routinely consumed little food or fluid, and urostomy output was often low or leaking. Meal intake was inconsistently documented, and fluid intake was not measured, even though the facility's electronic medical record system generated alerts for poor meal intake. The registered dietician and nursing staff acknowledged that they did not know how much fluid the resident actually consumed, and there was no evidence that supplement shakes were provided as ordered or that their consumption was tracked. The resident's responsible party raised concerns about dehydration and poor intake, but the facility's response was limited to investigating the complaint without implementing ongoing monitoring or interventions for hydration. In the days leading up to the resident's acute decline, documentation showed continued poor meal intake and low urostomy output, yet there was no indication that the medical provider was notified or that additional assessments for dehydration were performed. When the resident experienced a significant change in condition, staff were unable to obtain intravenous access for fluids, and the resident was ultimately transferred to the hospital, where he was found to be severely dehydrated and septic. Interviews with facility staff revealed a lack of communication and follow-through regarding the resident's hydration status, and the facility's own policy on urostomy care, which required monitoring and recording of fluid output, was not consistently followed.