Failure to Monitor and Enforce Physician-Ordered Fluid Restriction
Penalty
Summary
The facility failed to monitor and document a resident's fluid intake in accordance with a physician's order for a 1500 milliliter (ml) fluid restriction. The resident, who had a medical history of chronic kidney disease and congestive heart failure, was admitted with a care plan and physician's order specifying the fluid restriction. Despite these orders, documentation from both the Treatment Administration Record (TAR) and meal intake records showed that the resident consistently consumed fluids in excess of the prescribed limit on multiple days. Interviews with facility staff revealed inconsistencies and gaps in the monitoring process. The Registered Dietitian calculated the daily fluid amounts to be provided by nursing and dietary staff but did not monitor the actual amounts nursing provided. Nursing staff, including RNs and LPNs, documented fluids given during medication administration on the TAR and relied on nurse aides to report meal intake, but there was no comprehensive system to total the fluids from all sources. The Unit Manager acknowledged that he did not add up the total fluids from both medication administration and meals, and only reviewed the TAR, excluding meal intake documentation by nurse aides. The Director of Nursing confirmed that due to inconsistent and incomplete monitoring, it was difficult to determine if the resident's fluid intake adhered to the physician's order. The Medical Director noted that while the resident had a potential for fluid overload, the significance of exceeding the fluid restriction would depend on clinical symptoms or lab values, which were not reported as problematic in this case. The deficiency was attributed to the lack of a coordinated and thorough monitoring process to ensure compliance with the fluid restriction order.