Failure to Prevent Dehydration in Dependent Resident
Penalty
Summary
The facility failed to prevent dehydration for a resident who was dependent on staff for all care due to quadriplegia and other significant medical conditions, including autonomic dysreflexia, neuromuscular bladder dysfunction, acute cystitis with hematuria, and moderate protein calorie malnutrition. The resident was cognitively intact but unable to independently access fluids due to physical limitations, requiring assistance for all eating and drinking needs. Despite these needs, the care plan did not include a focus area for hydration, and there were no orders to monitor fluid intake and output or to observe for signs and symptoms of dehydration. The resident was sent to the emergency room with a high fever and dark, cloudy urine, where they were diagnosed with a urinary tract infection and dehydration, and received intravenous fluids. Upon return to the facility, the after-visit summary included an order to encourage increased fluid intake, which was acknowledged by a facility nurse. However, this order was not implemented, as there were no subsequent orders or documentation to monitor the resident's hydration status or fluid intake and output. Observations confirmed that the resident's water pitcher remained full throughout the day, and the resident reported receiving assistance with fluids only during meals, with no routine staff visits to help with drinking. Interviews with the DON and nursing staff revealed they were unaware of the dehydration diagnosis and the order to push fluids, and confirmed that the expected monitoring and assistance were not provided. The facility's own hydration policy, which requires systematic assessment, monitoring, and documentation of hydration status, was not followed for this resident.