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Based on medical record review, policy review, and staff interview, the facility failed to monitor fluid intake for residents on physician ordered fluid restrictions. This affected three (#3, #4 and #8) patients with the potential to affect all patients on fluid restrictions.

Findings include:

1. The medical record for Patient #3 revealed an admission date of 09/10/24 at 9:11 PM from an outside facility with a diagnosis of post operative right pelvic fracture with repair. The history and physical further stated this patient had high blood pressure, cirrhosis of the liver and lipidemia. Orders were placed by Staff E on 09/14/24 for fluid restrictions of 1500 milliliters (ml). There was no documentation of oral intake until 09/15/24 when 120 ml Juven supplement was documented for the twenty-four hour day. Intake on 09/16/24 had the supplement Juven 50 ml at 5:00 PM and again on 09/17/24 at 7:00 AM. There was no other documentation of oral fluid intake in the record. Intravenous (IV) fluids were documented when given.

Review of the facility policy titled "Fluid Restriction," dated 08/23/23, stated it is the policy of the nutrition department that fluid restriction orders will be implemented with the cooperation of the nursing department. The tray menu slips will be marked "fluid restriction" and adjustments made on selections. Nursing will monitor and record the fluid intake on the Intake and Output (I&O) in the medical record.

Interview with Staff D on 1/28/25 revealed IV medications cross over from the medication record for total intake. Staff D verified the medical record lacked documentation of any fluid intake for 09/20/24 or 09/21/24 with a one time Ensure documented on 09/22/24 and no oral fluid intake on 09/23/24, even though this patient was eating three meals per day. There was no documentation the staff were monitoring the fluid intakes to ensure it met the ordered restrictions.

2. The medical record for Patient #4 revealed an admission on 12/07/24 after having a mitral valve replaced and post operative stroke with weakness on the left side and congestive heart failure. Physician orders on admission were for 1200 ml fluid restriction. The record revealed the first documented intake was on 12/09/24 at 10:44 AM of 240 ml, then not again until 12/11/24 at 8:45 AM of 400 ml. There was no other documentation of the patient's fluid intake.

The findings of not monitoring fluid intakes for the patient's ordered restrictions was verified with Staff A, B and D on 01/28/25 at 12:10 PM.

3. The medical record for Patient #8 revealed an admission on 10/20/24 at 8:20 PM from an outside hospital with a diagnosis of myopathy post coronary artery bypass. Physician orders were written on 10/22/24 at 9:17 AM for 1200 ml fluid restriction along with orders for I&O.

The medical record contained a twenty-four hour oral fluid intake documented on 10/23/24 as 2060 ml, which was greater than the 1200 ml ordered fluid restriction. Output was documented as continent with frequency but no volume of output was measured as the policy instructs. Patient #8 was independent with meals provided three times per day with no consistent documentation of fluid intake.

The findings of not monitoring the patient's fluid intake, not documenting intake and output, and not following physician ordes for fluid restrictions was verified with Staff D on 01/29/25 at 10:00 AM.