Failure to Monitor and Adhere to Physician-Ordered Fluid Restrictions
Penalty
Summary
The facility failed to properly monitor and adhere to physician-ordered fluid restrictions for two residents with significant cardiac and renal conditions. Facility policy on weight assessment and interventions required the physician and multidisciplinary team to identify medical conditions and medications that may cause fluid and nutrient loss or inadequate availability of food or fluids. One resident with chronic diastolic heart failure had a physician order for a 1500 ml fluid restriction over 24 hours, with 840 ml to be provided with meals and 660 ml by nursing staff. Review of this resident’s Medication Administration Records (MARs) and 30‑day task documentation for February and March 2026, combined with the fluids provided at meals, showed that the resident’s total fluid intake exceeded the 1500 ml restriction on all 30 days reviewed. Another resident with chronic kidney disease stage 3 and chronic diastolic congestive heart failure had a physician order for a 2000 ml fluid restriction over 24 hours, with 1080 ml to be provided with meals and 920 ml by nursing staff, as well as an order for a medication pass of 60 cc twice daily (120 cc total per day). Review of this resident’s February and March 2026 MARs and 30‑day task documentation showed that the combined fluid intake from nursing staff and meals exceeded the 2000 ml restriction on 13 of 30 days, and the ordered 120 cc daily medication pass volume was exceeded on 19 of 30 days. Interviews with the dietician and culinary director revealed that dietary staff were not involved in ordering or monitoring fluid restrictions and that the culinary department followed standard fluid breakdown guidelines but did not document fluids provided with meals in the resident records. An interview with the NHA and DON confirmed that both nurses and nurse aides were documenting fluid intake in different places, making it difficult to determine the exact amount of fluids residents actually received.
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