Failure to Develop Person-Centered Dehydration Care Plan for High-Risk Resident
Penalty
Summary
Surveyors identified a failure by the facility to develop and implement a comprehensive, person-centered care plan with measurable objectives and timeframes for a resident with a medical history of dehydration. The resident, an elderly female with diagnoses including type 2 diabetes with hyperglycemia, dehydration, acute kidney failure, TIAs, hyperlipidemia, dysphagia, and renal failure, had been admitted and later readmitted to the facility. Her MDS reflected a BIMS score of 02, indicating severe cognitive impairment, and physical impairments in one upper extremity and both lower extremities. Despite this history and a hospital history and physical documenting dehydration, the facility did not have a specific care plan addressing dehydration. Record review showed that the resident’s care plan dated 01/15/2026 did not include any problem, goal, or interventions related to her medical diagnosis of dehydration. The Physician’s Order Summary also did not contain an order for maintaining the medical diagnosis of dehydration. The DON acknowledged during interview that the resident’s care plans contained nothing regarding dehydration or how to prevent it, and stated that the risk of having no care plan for dehydration would be that the resident could dehydrate again and be readmitted to the hospital. The Administrator similarly stated that, given the resident’s medical diagnosis of dehydration and history of hospitalization for dehydration and UTIs, there should have been a care plan. The MDS nurse reported that care plans are developed on admission, quarterly, and with any change in condition, and that nursing staff share responsibility for reviewing care plans and ensuring they are correctly entered into the electronic system. The MDS nurse stated there was no specific order for the resident’s medical diagnosis of dehydration, but asserted there was no risk because a care plan for “risk for altered fluid balance” existed, with interventions such as evaluating blood pressure and educating the resident/representative on methods to relieve dry mouth while maintaining fluid restriction. However, this care plan did not specifically address the resident’s dehydration diagnosis. Facility policy on comprehensive person-centered care plans required measurable objectives and timetables to meet residents’ needs, reflect current standards of practice, address underlying sources of problems, and be revised upon changes in condition or readmission from the hospital, but these requirements were not met for this resident’s dehydration.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.