Failure to Monitor and Document Fluid Intake for Resident on Fluid Restriction
Penalty
Summary
The facility failed to adequately monitor and manage fluid intake for a resident on a physician-ordered fluid restriction, resulting in a failure to ensure proper hydration and adherence to the ordered restriction. Facility policy titled "Fluid Restriction" assigned nursing services responsibility for tracking and documenting total volume consumed, but the policy did not provide guidance on what measures staff should take if a resident exceeded ordered fluid restrictions. The resident had diagnoses including acute on chronic diastolic congestive heart failure and hypertensive heart and chronic kidney disease with heart failure, and had an order for a regular/liberalized diet with a 1500 cc fluid restriction, divided as 800 cc from dietary and 700 cc from nursing. The resident’s care plan identified risk for dehydration and nutritional risk, with interventions such as offering small amounts of fluids frequently and enforcing the 1500 ml fluid restriction, but the nurse aide Kardex only noted that the resident was on fluid restrictions without further directions. The dietary tray ticket indicated a 1500 ml per day restriction and a maximum of 240 ml per meal. Review of Medication Administration Records from August through mid-March showed that the resident exceeded the allotted nursing fluid portion on multiple dates across several months. Despite these repeated exceedances, the clinical record contained no documentation that the physician was notified when the resident went over the ordered nursing fluid allowance. Additionally, there was no documentation of fluids consumed from meal trays during this period, so the resident’s total 24-hour fluid intake was not determined. In an interview, the DON confirmed there was no documentation of dietary fluid intake with meals, that nurse aides verbally reported fluids to nurses, that the resident did exceed allotted nursing fluids on some occasions, and that there was no documentation showing all fluids were totaled for each 24-hour period, despite the expectation that staff follow fluid restriction orders and notify the physician when they are exceeded.
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