Failure to Update Care Plan for IV Fluids After Assessment
Penalty
Summary
The deficiency involves the facility’s failure to ensure a comprehensive care plan was reviewed and revised by the interdisciplinary team after assessments for one resident. The resident was an elderly female admitted with diagnoses including severe dementia due to an underlying physiological condition, dysphagia in the pharyngeal stage, and severe protein-calorie malnutrition. Record review showed that the resident’s comprehensive care plan, dated 12/25/2025 and 01/12/2026, did not include or reflect the initiation of IV fluids. Physician orders dated 01/12/2026 documented an order for Lactated Ringers IV solution, and the MDS assessments, including one dated 01/13/2026, indicated that parenteral/IV fluids (K0520A) were provided during the look-back period. Interviews and policy review further supported the deficiency. The DON stated that an IV is a significant change and should be included in the care plan, but she was unable to state how soon it should be added. The MDS Coordinator confirmed that the IV fluids for dehydration were not included in the resident’s care plan and stated that the care plan should have been updated immediately, noting that the MDS did indicate the use of IV fluids. Review of the facility’s comprehensive care plan policy, implemented 10/24/2022, documented that the comprehensive care plan will be developed within 7 days after completion of the comprehensive MDS assessment and that all care assessment areas triggered by the MDS will be considered in developing the plan of care. Despite this policy, the resident’s care plan was not updated to reflect the IV fluids for dehydration.
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