Fluid Restriction Not Followed for a Resident: A resident with CHF, ESRD, and respiratory failure was on an 1800 ml fluid restriction, but nursing, dietary, and nursing aide documentation showed the resident received more fluid than allowed on multiple days. The MAR documented nursing fluids, the tray card documented dietary fluids, and a fluid tracking form documented additional fluids, but the totals were not combined in the record review, and the resident consumed amounts above the ordered restriction.
Failure to monitor and document fluid restriction intake led to two residents receiving fluids outside ordered limits. One resident with CHF had a 2000 mL/day fluid restriction, but a water pitcher was kept at bedside, the diet slip did not reflect the restriction, and nursing and dietary communication was inconsistent. Another resident with hyponatremia had a 1500 mL/day free water restriction, yet bedside pitchers and visitor-provided water were observed, shift totals were not calculated into 24-hour intake, and the record showed no documentation of education or provider notification when the restriction was exceeded.
Failure to monitor and address significant weight loss. Two residents had documented nutritional risk and ongoing weight loss, but weights were not consistently obtained or reviewed, and the RD did not identify or add further interventions. One resident with orthopedic aftercare and UTI lost 11% in one month with low protein and albumin labs, while another resident with MI, HF, and depression lost 12.3% over 73 days despite a soft diet and supplemental shakes. Staff and the RD acknowledged the weight loss, but no additional nutritional assessments or interventions were identified.
Failure to monitor and address nutritional needs led to weight loss and poor meal intake for four residents. One resident with ESRD on dialysis, DM2, malnutrition, and swallowing complaints refused a sugary supplement and lost significant weight; another resident with dementia and malnutrition could not manage utensils and lost weight; a resident with dementia and hearing loss struggled to eat because staff did not assist promptly and also lost weight; and a fourth resident on a restorative eating plan was moved between tables, had delayed meal support, and ate only a few bites. The nutrition-at-risk record lacked recent notes for these residents, and staff interviews showed gaps in awareness of the weight loss and food preference details.
A resident with severe cognitive impairment and communication deficits experienced progressive weight loss from 108 lbs to 90.8 lbs over about five months, while the facility continued the same general supplement regimen and did not document food preference evaluations or a change to NEM, fortified foods, or calorie-dense meals. Meal records showed the resident usually ate only 0-25% of meals, and MNA findings documented worsening intake and malnutrition, but no follow-up recommendations were recorded. Staff confirmed the resident’s preferred foods were known but not documented, and no additional nutritional interventions were identified.
The facility failed to follow care plans and orders for meal assistance and weight monitoring for several residents. A resident with dementia, stroke, and swallowing difficulties, on aspiration precautions and ordered for 1:1 supervision with meals, was repeatedly observed eating independently in bed without staff present, while NAs cited staffing issues and gave conflicting statements about the resident’s need for assistance. Another resident, at risk for weight loss and with abdominal surgical wounds, experienced a notable weight decline over about two months without any assessment or interventions documented in the medical record, despite staff stating weight loss should be reviewed in weekly meetings. A third resident with dementia and CHF, ordered to receive tray setup, 1:1 and intermittent supervision, and bolt-upright positioning for meals, had a tray left unsetup, ate with the head of bed partially elevated and no staff present, and also had documented weight loss that was not addressed or recorded in the chart.
A resident with severe cognitive impairment and multiple health conditions received subcutaneous fluids for dehydration, but staff failed to properly monitor, document, and administer the infusion as ordered by the physician. The infusion bag and dressing lacked required labeling, the infusion rate was set below the prescribed amount, and there was no documentation to confirm when the infusion started or who initiated it. Nursing staff did not follow physician orders or facility policy, resulting in the resident receiving fluids at a slower rate than ordered for two days.
A resident did not receive enough food and fluids to maintain their health, as observed and documented by surveyors. The facility did not meet the nutritional and hydration needs required to support the resident's well-being.
A resident with complex medical needs did not have required admission or weekly weights obtained, despite physician orders and care plan directives. The dietician's recommendation for a nutritional supplement was not communicated to the physician, resulting in the resident not receiving the supplement. The DON confirmed these lapses in care.
Three residents with complex medical conditions experienced deficiencies in nutrition and fluid management due to inaccurate meal intake documentation, unclear communication of fluid restrictions between nursing and dietary staff, and lack of monitoring for residents on fluid restrictions. Staff interviews confirmed that intake records were not accurately maintained and that fluid restriction protocols were not consistently followed.
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