F0684

D

Failure to Monitor and Document Fluid Intake for Resident on Fluid Restriction

Pawtucket, Rhode Island Survey Completed on 01-22-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that a resident with fluid restrictions received treatment and care in accordance with physician orders and professional standards. The resident was re-admitted in December 2025 with diagnoses including hypo-osmolality and hypernatremia, and had a care plan noting potential for fluid overload related to polydipsia and hyponatremia. A physician’s order dated 12/12/2025 directed staff to encourage the resident to limit fluid intake every shift for monitoring. After the resident was found on the bathroom floor with a large lump on the forehead and sent to the hospital, the hospital documented psychogenic polydipsia and hyponatremia with a sodium level of 119 and serum osmolality of 252, and recommended a 1500 mL fluid restriction.

Following this, a 12/24/2025 physician order specified a 1500 mL/day fluid restriction with detailed allocations for dietary and nursing fluids per meal and per shift, and the NP reinforced the importance of adherence and instructed nursing staff to monitor daily fluid intake and report acute changes. Despite these orders, staff interviews revealed that NAs did not document or communicate the amount of fluids consumed for any residents, while an LPN stated that fluid intake for this resident was documented by NAs and signed off as completed in the TAR. Record review showed that the fluid restriction orders were only marked as completed with check marks, with no documentation of the actual amounts of fluid provided or consumed per shift as ordered. The Medical Director stated an expectation that intake amounts be monitored and documented per shift, and the Administrator acknowledged that the facility failed to monitor the resident’s fluid intake according to the physician’s order.