F0692

E

Failure to Monitor and Enforce Fluid Restrictions for Dialysis Residents

Van Nuys, California Survey Completed on 03-12-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow its intake and output (I&O) policy and physician-ordered fluid restrictions for residents on dialysis. For one resident with end stage renal disease, type 2 diabetes mellitus, and dependence on renal dialysis, the physician’s order and care plan specified a 1,500 mL daily fluid restriction divided among nursing and dietary shifts. The Assistant Director of Nursing (ADON) explained that licensed nurses were to document fluids they provided on an I&O record, CNAs were to document fluids they provided in the electronic health record, and that the combined total for each 24-hour period should not exceed the ordered restriction. However, review of CNA fluid intake documentation and the licensed nurses’ I&O records from multiple dates showed that the resident’s total daily fluid intake consistently exceeded the 1,500 mL restriction, ranging from 1,650 mL to 3,300 mL per day.

The ADON stated that only fluids provided by licensed nurses and from the kitchen should be offered to residents on fluid restrictions, and that CNAs should inform licensed nurses before offering fluids to such residents for proper monitoring. The ADON acknowledged that the facility failed to monitor this resident’s intake according to the physician’s order and that licensed nurses should have communicated with each other, including during huddles, to remind CNAs which residents were on fluid restrictions. This failure resulted in repeated instances where the resident received more fluid than prescribed over an 11-day period.

A second resident, also with end stage renal disease, dependence on renal dialysis, and hypertension, had a physician’s order, care plan, and dietary evaluation specifying a 1,000 mL fluid restriction divided among breakfast, lunch, and dinner, with PO intake to be monitored. Review of CNA task documentation over a one-month period showed that this resident’s daily fluid intake exceeded the 1,000 mL restriction on multiple dates, with recorded intakes between 1,050 mL and 1,220 mL. During interview and record review, the ADON confirmed that the resident received more fluids than ordered on those dates and stated that licensed nurses should have monitored the resident’s fluid intake to ensure it did not exceed 1,000 mL. The facility’s written I&O policy required nursing assistants to document all fluids consumed on a daily I&O sheet, licensed staff to document fluids given with medications, and the 3–11 shift to total 24-hour intake each day, but the documented intakes show that these monitoring and documentation processes did not prevent the residents from exceeding their ordered fluid restrictions.