Fluid Intake Documentation (Kansas)
A long-term care community was cited for failure to monitor hydration status on a resident. The resident had an active care plan in place to address a urinary tract infection (UTI) as well as a care plan for being at risk for dehydration. The resident was also on a fluid restriction. The care plans and resident physician orders indicated the appropriate amounts of fluid to be provided at each medication administration and at each meal. The surveyors reviewed the medication administration record for the resident and identified several dates with missing documentation of fluid intake and on many occasions, the fluid amounts recorded exceeded the maximum amount that was indicated per the care plan and physician orders. The surveyors also identified missing documentation of fluid intake in the resident electronic medical record (EMR). Upon the interview with the resident, they stated they were confused and received mixed messages with how much fluid to consume because of the contraindication of limited fluid intake and need for increased fluid due to the UTI and dehydration risk. The interview with several staff members indicated lack of consistent methods on monitoring and documenting fluid intake. Due to these observations, the community received a deficiency for potential risk of fluid overload or fluid deficit for this resident.
In response to the survey findings, the registered dietitian and corporate clinical leader conducted a joint inservice for the dining service, activity, and nursing teams. The training included a review of how to properly document fluid intake in the EMR system and the corporate policy and procedures on managing fluid restrictions. The CDM began reviewing fluid documentation for all residents on fluid restrictions as part of the weekly nutrition at risk meeting. These steps significantly improved the consistency and accuracy of monitoring and documenting fluid intake where needed. In addition, the community leadership was able to quickly identify gaps when they occurred and immediately conduct targeted training which improved their ongoing compliance with this process.