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Dehydration – A Silent Killer In Nursing Homes (part 2)
In our last article, we discussed how nursing homes that allow patients to become significantly dehydrated may be committing a form of silent patient neglect. In this article, we will discuss how nursing homes are obligated to ensure certain precautions are taken to prevent patients from suffering dehydration, which can often lead to other serious health problems (such as pressure sores) and be deadly itself.
EFFECT OF NURSING HOME UNDERSTAFFING
Preventing dehydration is a matter of implementing simple but effective measures aimed at ensuring adequate levels of fluid and nutrition intake. Ultimately, the key to proper hydration and nutrition in the nursing home setting is having an adequate number of properly trained and supervised staff. This reality that was confirmed long ago by the American Medical Directors’ Association:
“Adequate, competent staff working under skilled supervision are essential to maintaining an appropriate hydration program. Designated members of the care staff should be expressly assigned responsibility for assisting with patient intake of fluids”
(AMDA Clinical Practice Guideline – Dehydration and Fluid Maintenance in the Long Term Care Setting, 2001).
Lawmakers too have long been aware of the problem. In 2003, noted Department of Health Policy and Management Director at Southwest Rural Health Research Center Professor Catherine Hawes, Ph.D. offered the following testimony before the U.S. Senate Committee on Finance, which highlights the impact of understaffing on dehydration and malnutrition (Hawes, 1997):
“A discussion of ‘staffing” and “ratios’ sounds technical. However, CNAs are eloquent about what it means to work short-staffed. What gets ignored first, out of necessity, according to CNAs, is range of motion exercises — which leads to contractures. Next, staff report, they are unable to provide sufficient help with eating and drinking. Undernutrition, malnutrition, and dehydration inevitably follow such neglect, with the concomitant sequelae of skin breakdown, pressure ulcers, poor healing of wounds, and premature mortality — not to mention the daily misery of being hungry and thirsty.”
NURSING HOME REGULATIONS
Because of the importance of proper hydration and nutrition, federal regulations require nursing homes to take specific steps to ensure the safety and well-being of patients. Below are some of the regulations that impose a duty upon the nursing home to make sure the patient receives the hydration they need to maintain health:
SUFFICIENT FLUID INTAKE
• The facility must ensure that the patient is offered sufficient fluid intake to maintain proper hydration and health. 42 C.F.R. §483.25 (g)(2)
This means that the nursing home is responsible for ensuring the patient receives the intake they need. Period. This is a vital part of the care that the nursing home is being paid to provide. This means the nursing home must have assessed what the patient’s intake needs are, and then must ensure the patient is provided the intake that corresponds to the patient’s needs.
• The facility must ensure that a patient who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers. 42 C.F.R. §483.25 (g)(5)
This means that the nursing home must ensure that patients who receive intake by mouth, with supplements, or with tube feedings must receive the treatment and services needed to prevent dehydration, among other things.
SUFFICIENT AND PROPERLY TRAINED STAFF
• The facility must employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration patient assessments, individual plans of care and the number, acuity and diagnoses of the facility’s patient population. 42 C.F.R. §483.60 (a).
This regulation requires the nursing home to hire enough properly trained staff to make sure the patients receive the nutrition and hydration they require. Understaffing is all too common, but never a good excuse. Nursing homes are paid to ensure there is enough staff.
PALATABLE AND ACCORDING TO THE PATIENT’S DESIRES
• The facility must ensure that food and drink that is palatable, attractive, and at a safe and appetizing temperature. 42 C.F.R. §483.60 (d)(2)
Warm, stale water is not palatable and is likely to cause patients to avoid drinking as much as they should. The water and hydration available to patients should be attractive, safe, and served at desired temperatures.
• The facility must ensure that patients are provided drinks, including water and other liquids consistent with patient needs and preferences and sufficient to maintain hydration. 42 C.F.R. §483.60 (d)(6)
This means that the patient decides what they get to drink, and how it is served. Some like cold tea, others prefer hot. Nursing homes must help patients get the hydration they need by serving drinks the way the patient desires them.
AT LEAST 3 MEALS DAILY
• The facility must provide — and must ensure that each patient receive — at least three meals daily, at regular times comparable to normal mealtimes in the community or in accordance with patient needs, preferences, requests, and plan of care. 42 C.F.R. §483.60 (f)(1)
Meals often represent a period during which patients consume significant amounts of fluid. Nursing homes must ensure that patients are offered at least 3 meals daily. Anything less is in violation of the nursing home regulations which facilities must comply with.
• The facility must provide special eating equipment and utensils for patients who need them and appropriate assistance to ensure that the patient can use the assistive devices when consuming meals and snacks. 42 C.F.R. §483.60 (g)
If a patient needs a straw or some other assistive device in order to ensure the patient can consume the meal or drink, the nursing home must ensure that is provided.
If you observe that a patient is not receiving adequate hydration, or that a nursing home is violating any of these important regulations enacted to prevent patient dehydration, you can file a nursing home complaint. Reporting incidents of nursing home neglect is important, as it can protect both current and future patients of the facility, and help uncover substandard care that has become all-to-common in today’s nursing home industry.
It is astonishing that any nursing home patient in this country should ever have to endure the daily misery of being hungry and thirsty. Proper nutrition and hydration represent the most fundamental level of care — the very least — that nursing homes promise to, should be able to, and are being paid to provide for all patients.
In our next article, we will discuss what you can do to help ensure that you or your loved one receives proper hydration while in a nursing home.
Jeff Powless is an attorney and the author of the 2017 book, Abuses and Excuses: How To Hold Bad Nursing Homes Accountable. Abuses and Excuses breaks new ground in helping patients and families hold bad nursing homes accountable, sharing a wealth of insider strategies and insights. It’s an eye opening account of corporate greed, acts of neglect and abuse, an insidious industry culture of cover-up, and the actual harm that inevitably befalls vulnerable nursing home patients all across the country with shocking frequency.
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