Failure to Assess and Document Resident Hydration Needs
Penalty
Summary
A deficiency was identified regarding the facility's failure to adequately assess and document the hydration needs of a resident following admission. The resident, who had recently been discharged from the hospital with a noted increase in creatinine and BUN levels, was admitted with multiple diagnoses including cervical spine fusion, cognitive communication deficit, and weakness. Upon admission, the resident was alert and oriented, with normal abdominal findings and independence in eating. However, the medical provider's note did not specify fluid intake goals, and a physician's order was issued to monitor intake and output (I&O) every shift for 72 hours and document it on the appropriate flowsheet. Review of the I&O documentation revealed significant gaps. There was no I&O documentation for the day of admission, and incomplete records for the following day, with missing entries for several hours and no 24-hour estimated fluid needs recorded. Over the subsequent days, the resident's total fluid intake was consistently below the estimated needs, and the required estimated fluid needs were not documented until several days after admission. Additionally, there was no evidence of a nursing hydration assessment or a nutritional assessment after admission or following a syncopal episode and findings of constipation and abdominal distension. Interviews with facility staff confirmed that hydration assessments should be completed on admission and readmission, and that both nursing and dietary staff are responsible for calculating and documenting fluid needs. The dietitian acknowledged that she may not have assessed the resident due to her limited schedule and the resident's hospital stay. The facility's hydration policy requires at-risk residents to be reviewed and provided with interventions to promote hydration, and mandates that I&O be documented for each shift for 72 hours post-admission. These requirements were not met in this case, resulting in the identified deficiency.