Failure to Monitor and Document I/O for Resident on Fluid Restriction
Penalty
Summary
The deficiency involves the facility’s failure to monitor and document intake and output (I/O) for a resident on physician-ordered fluid restriction, in accordance with professional standards and facility policy. The resident was originally admitted with diagnoses including acute on chronic diastolic CHF, chronic pulmonary edema, and orthostatic hypotension, and was dependent on staff for ADLs but cognitively intact. On readmission, the RN hospital-to-facility admission report and physician’s telephone orders specified a fluid restriction of 750 ml per day due to chronic pulmonary edema, and a subsequent physician’s order directed that no water pitcher be left at the bedside. The facility’s I/O record for this resident showed monitoring and documentation from 12/30/2025 to 1/7/2026 only. During interviews and concurrent record reviews, an LVN confirmed that licensed nurses did not monitor or document the resident’s I/O after 1/7/2026 despite the ongoing fluid restriction order. An RN similarly stated that, given the 750 ml per day fluid restriction and the order for no bedside water pitcher, licensed nurses should have continued to monitor I/O closely, particularly in light of the resident’s heart problems and history of edema. Review of facility policies titled “Fluid Intake and Output” and “Resident Hydration and Prevention of Dehydration” showed that intake and output must be recorded for residents with restricted fluids as ordered by the physician, with daily I/O documented for a minimum of 30 days, and that nursing will monitor and document fluid intake when inadequate intake or dehydration concerns are present. The facility did not follow these policies for this resident after 1/7/2026.
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