Sallie Brown was a frail, 79-year-old lady admitted to Healthy Place Nursing Home after her husband of 60 years suddenly died. She was at risk for dehydration and malnutrition.
At the time of admission, Mrs. Brown weighed 120 pounds and was fifty-nine inches in height.
The medical diagnoses included depression, congestive heart failure, and dysphagia (difficulty swallowing).
The physician’s orders included a daily diuretic to remove excess fluid from the body. The orders did not include an antidepressant. The orders documented that Mrs. Brown was to receive four ounces of high protein supplement twice daily. The physician’s orders documented that the resident was to be weighed once monthly. Sallie’s daughter paid extra to have a person feed her mother at each mealtime.
Mrs. Brown had a significant weight loss of 26.7% (32 pounds) in one month. She began having dark urine, with decreased urine output, increased confusion, and fever.
The resident was admitted to the hospital with severe dehydration, acute kidney injury, urinary tract infection, and aspiration pneumonia, which all contributed to her death five days after admission.
Sallie’s daughter Lisa went to a plaintiff’s attorney to find out what happened to her mother. When the hospital notified her of her mother’s death, Lisa called the nursing home to ask questions about what led up to the hospital admission. “We can’t tell you anything,” they said. That reaction fueled Lisa’s anger and desire for answers.
Lisa’s attorney requested a copy of the nursing home record and retained a legal nurse consultant to evaluate the care Mrs. Brown received.
When the LNC opened the chart, she considered these elements of care:
Key Elements of Care in Preventing Malnutrition and Dehydration
The medical record analysis would focus on whether the facility did not do one or more of the following:
- Accurately and consistently assess a resident’s nutritional status on admission and as needed thereafter.
- Show a resident at nutritional risk and address risk factors for impaired nutritional status, to the extent possible.
- Show, implement, monitor, and change interventions (as appropriate), consistent with the resident’s assessed needs, choices, preferences, goals, and current professional standards of practice to support acceptable parameters of nutritional status.
- Notify the physician as appropriate in evaluating and managing causes of the resident’s nutritional risks and impaired nutritional status.
- Name and apply relevant approaches to support acceptable parameters of resident’s nutritional status, including fluids.
- Provide a therapeutic diet when ordered.
- Offer sufficient fluid intake to support proper hydration and health (Centers for Medicare and Medicaid Services (CMS) State Operations Manual (SOM)483.25g, F692, revised 08/2024).
Clinical Consequences of Dehydration and Malnutrition
Failure to show residents at risk for compromised nutrition and hydration may be associated with an increased risk of mortality and other negative outcomes.
The standard menu represents equal serving amounts for each resident unless the recommendation by the dietitian was different, based on the resident’s identified needs. Malnutrition most usually presents itself as decreased amount of food intake for reasons that might include that the resident’s preferences were not considered, the amount of assistance was not identified/implemented, the resident did not eat the food provided, substitutes or supplements were not being provided, or therapeutic diet orders were not being followed.
The consequences of malnutrition can include development of pressure injuries or impairment in healing of the pressure injuries, decline in function, and unplanned weight change. Depression is a major factor in poor food intake and weight loss. Severe weight loss is determined when the resident has lost more than 5% in a month (CMS, 483.25g, F692, 2024).
Dehydration on the other hand, can also cause devastating changes. Ensuring a resident receives the fluids they need can be more challenging, especially if a formal monitoring system is not put into place. Individuals who do not receive adequate fluids are more susceptible to urinary tract infections, pneumonia, pressure injuries, skin infections, confusion, fluid and electrolyte imbalance, and disorientation. Severe infections can lead to sepsis which causes multiple body systems to fail. Dehydration is a major contributor to weight loss.
Acute kidney injury (AKI) is a term used to describe when the kidneys are suddenly not able to filter waste products from the blood and can occur within a few hours or a few days. For most people, AKI develops within 48 hours, but sometimes it can take as long as seven days.
AKI can have numerous different causes. Many people get AKI when a related disease or condition puts extra stress on their kidneys.
Usually, AKI happens because of a combination of factors of which dehydration is a major consideration. This is especially true for older adults who are at higher risk given their age.
AKI can cause a build-up of waste products in the blood and make it hard to keep the right balance of fluid and minerals in the body. It can also cause permanent damage to the kidneys, leading to chronic kidney disease (CKD). Without treatment, AKI can also affect other organs such as the brain, heart, and lungs.
After having AKI, the patient has a higher risk for other health problems, such as chronic kidney disease (CKD), heart disease, or stroke. They are also at a higher risk of getting AKI again in the future.
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Janet Pearce, RN has been a nurse for 49 years. Her experience includes hospital medical/ surgical, home health, hospice, and 35+ years of long-term care. During her career in long-term care, she has held various positions including charge nurse, director of nurses, nursing home administrator, infection preventionist, and certified Clinical Health Facility Surveyor (nursing home inspector). Janet worked 12 1/2 years doing annual and complaint inspections for the state department of health to ensure long-term care facilities followed the CMS State Operations Manual. Medical record review and analysis are integral parts of showing non-compliance and the severity level of the deficient practices.
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