Failure to Incorporate Fluid Restriction Orders into Comprehensive Care Plan
Penalty
Summary
Surveyors identified that the facility failed to develop and implement a comprehensive, person-centered care plan with measurable objectives and timeframes for a resident who had a physician’s order for fluid restriction. The resident was admitted in October 2025 with diagnoses including hypo-osmolality and hyponatremia, a condition characterized by excess body water relative to sodium. Record review showed dietary physician’s orders starting 10/14/2025 specifying thin liquids with no free water due to fluid restriction and a regular texture diet with a fluid restriction with meals. Further review of the clinical record did not reveal any evidence that these fluid restriction orders were incorporated into the resident’s comprehensive care plan. In an interview, the Director of Nursing Services stated she would have expected the physician’s order for the fluid restriction to be included in the resident’s comprehensive care plan. This deficiency was cited for 1 of 1 residents reviewed who had a physician’s order for a fluid restriction, as the facility did not ensure that the resident’s medical, nursing, and psychosocial needs related to fluid restriction were addressed through a comprehensive care plan.
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.