F0692

G

Failure to Monitor and Manage Hydration Leading to Recurrent Dehydration and Hospital Transfers

Beaver Dam, Wisconsin Survey Completed on 02-18-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that a resident received sufficient fluids to maintain proper hydration and health. The resident was admitted with multiple significant diagnoses, including muscle wasting and atrophy, morbid obesity, polyneuropathy, chronic pain syndrome, atrial fibrillation, HTN, seizures, CKD stage 3, mood disorder, and wounds. The resident’s H&P by the NP directed that fluid status be closely monitored, but facility leadership gave differing and unclear interpretations of what this meant, and there was no documented clarification. The facility was unable to provide a hydration policy when requested by the surveyor.

The RD established an estimated fluid need of 2376–2640 ml/day and documented that the resident was at risk for malnutrition, with a goal that the resident maintain good skin integrity with no signs of dehydration or malnutrition. Fluid intake records show that the resident frequently did not meet the recommended fluid goals over multiple extended periods. From late November through mid-December, the resident failed to meet fluid goals on most days, yet there is no documentation that the RD or provider were notified when intake was consistently low. The RD later stated that several stretches of poor intake should have triggered notification and additional interventions, but the RD was not informed. Nursing leadership acknowledged that when fluid goals are not met, nurses should assess the resident, evaluate skin and mucous membranes, check vital signs, and notify the provider and RD, but there was no documentation that this occurred.

The resident experienced multiple changes in condition associated with dehydration and was sent to the ED/hospital three times, each time receiving IV fluids for dehydration. On the first ED visit, the resident presented with kidney pain, dry mucous membranes, and difficulty speaking; the ED provider documented very dry, shriveled tongue and lack of saliva, administered 2 L of IV fluids, and instructed that the resident be orally rehydrated with water and electrolyte drinks. There is no evidence in the medical record that electrolyte drinks were provided, that a hydration assessment was completed, or that monitoring or new interventions were implemented after this visit. Subsequent fluid intake records continued to show frequent failure to meet fluid goals, including consecutive days of poor intake, and the RD again reported not being notified of these patterns or of the ED visits and IV fluid administration.

Later, the resident was sent to the hospital with altered mental status, difficulty arousing, and nonsensical speech; the hospital discharge summary documented a diagnosis of dehydration and IV hydration. After return, fluid intake again did not meet estimated needs on all recorded days, and documentation shows inconsistent or low intakes, with CNAs indicating that “not applicable” entries meant zero intake. The resident was again sent to the ED with altered mental status, difficulty staying awake to swallow food/medications, and labored respirations, and was diagnosed with dehydration and given 3 L of IV fluids. ED discharge instructions again emphasized ensuring adequate fluids. The DON stated that full nursing assessments and 72-hour monitoring should occur after hospital returns, including ensuring adequate fluid intake and daily vital signs, but acknowledged that these assessments were not found in the chart. Overall, the facility did not complete hydration assessments, did not consistently monitor and document fluid intake against established goals, did not notify the RD or provider when indicated, and did not implement additional interventions to prevent recurrent dehydration, resulting in three hospital transfers for dehydration and IV fluid treatment.