Nursing home neglect and abuse can manifest itself in many obvious ways, including the development of pressure sores, injuries from abusive handling or being allowed to unnecessarily fall, etc. But it is important to keep in mind that neglect and abuse in a nursing home can result in more subtle or less obvious harms, including dehydration and malnutrition.

Take, for example, the following real-life scenario that demonstrates the catastrophic effects that can result when a nursing home neglects a patient’s hydration and intake needs:

Eighty-one-year-old “Theresa,” a loving wife, mother, and grandmother, suffered debility following a recent hospitalization and had difficulties walking and performing many of her daily living activities. With the assistance of her husband, she was able to cope and live at home. But one day, Theresa fell at home and, although she broke no bones, she suffered a number of injuries and needed advanced care and monitoring, which her husband, in light of his own increasing debility, was unable to provide. Theresa was taking medication for cognitive deficits such as confusion and required professional nursing care and therapy services. She was admitted to a local nursing home. But unbeknownst to Theresa and her family, this nursing home facility had recently been cited by state surveyors for various care deficiencies, including the failure to properly care for patients who were at risk for dehydration. When Theresa was admitted to the nursing home, she was known to be at risk for fluid balance fluctuation (caused by dehydration).

In the weeks to come, the nursing home staff failed to assess whether Theresa was receiving proper hydration. She was supposed to receive at least 30 cc’s/kg of fluid intake each day, or approximately 2,000 cc’s per day. Instead, the nursing home’s own intake records showed that Theresa was receiving significantly less than half that amount on many days, and sometimes received less than 100 cc’s in a given day. Theresa’s physician was never made aware of this significant fluid insufficiency, nor was she notified of Theresa’s decline. In fact, there was no indication that the nursing home staff even assessed Theresa’s hydration intake during that critical time period, despite the fact that they noted that Theresa was “lethargic” and “moaning out”.

Ultimately, Theresa was transported by ambulance to the local hospital, where the emergency staff noted Theresa’s lips were “very dry and cracked” and that she was
unresponsive to any stimuli. The emergency room staff also documented that Theresa’s mucous membranes were very dry and pale and a “large amount [of] dried food and sputum [were] suctioned from [her] mouth.” She had become so dehydrated that she was literally unable to form the saliva necessary to swallow her food. Blood tests confirmed her condition; she was diagnosed with severe dehydration, acute renal failure, urosepsis, and possible aspiration pneumonia, which was likely due to receiving inadequate fluid intake. Her condition deteriorated and she died several days later.

Powless Law Firm filed suit on behalf of Theresa’s family and discovered critical information that, had Theresa and her family known it at the time, would have led them to have her admitted to another nursing home.

Unbeknownst to Theresa’s family, the facility had been cited by state investigators prior to Theresa’s admission, and investigators found that on 27 of 30 days in the month reviewed, another patient received at least 600 cc’s of fluid less than the patient needed. The investigator noted: “Documentation was lacking to reflect the 24-hour totals and ongoing assessments of intake and status communication to the physician prior to dehydration and complications warranting hospitalization.” To address the citation, the nursing home administrator submitted a plan of correction which included the promise that the facility would offer special training to its employees on hydration issues. But according to one facility employee, this training never happened. This employee testified during her deposition that she was never made aware by facility administrators that state investigators had concerns about patient hydration, nor did she recall any special hydration training during this period.

This broken promise likely caused Theresa’s premature death.

The Importance of Hydration and Nutrition To The Elderly

In 1974, Dr. C.E. Butterworth suggested in Nutrition Today that malnutrition was “the skeleton in the hospital closet” (Butterworth, 1974). But in the 1970s, studies had yet to document that an even more ominous skeleton was lurking in nursing home closets as well: Dehydration.

The importance of proper hydration to human health cannot be over-emphasized. Water accounts for about two‑thirds of the average adult’s total body weight. As humans age, this percentage decreases to about 50% for elderly males; 45% for elderly females (Davis et al., 1998). Dehydration and fluid/electrolyte imbalances can lead to serious health consequences, including death.
Nutrition provides the energy and building blocks required for all bodily processes and fuels the body’s ability to maintain and repair its structures. Inadequate nutrition impairs these processes and can prevent the body from carrying out vital functions necessary to maintain itself.

Malnutrition and dehydration in elderly populations are associated with poor clinical outcomes and increase the risk of mortality. Patients with severe malnutrition are at higher risk for a variety of complications and a number of chronic medical conditions, such as cardiac and pulmonary diseases, cancer, impaired immunity, infections and many others (Thomas et al., 2000).

Preventing dehydration and malnutrition in nursing home patients is a matter of 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, as in so many contexts, an adequate number of properly trained and supervised staff, a reality that has been confirmed 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” (American Medical Directors Association, 2001).

Nursing Home Regulations Pertinent to Proper Hydration and Nutrition

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 These regulations impose specific requirements upon nursing homes,, including the following:

• The facility must ensure that a patient who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition. 42 C.F.R. §483.24 (a)(2)
• The facility must ensure that the patient maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the patient’s clinical condition demonstrates that this is not possible or patient preferences indicate otherwise. 42 C.F.R. §483.25 (g)(1)
• 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)
• The facility must ensure that the patient is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet. 42 C.F.R. §483.25 (g)(3)
• The facility must ensure that a patient who has been able to eat enough alone or with assistance is not fed by enteral methods unless the patient’s clinical condition demonstrates that enteral feeding was clinically indicated and consented to by the patient. 42 C.F.R. §483.25 (g)(4)
• 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)
• The facility must provide each patient with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each patient. 42 C.F.R. §483.60
• 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. This includes: 42 C.F.R. §483.60 (a)
• The facility must ensure that menus meet the nutritional needs of patients in accordance with established national guidelines, be prepared in advance; be followed; Reflect, based on a facility’s reasonable efforts, the religious, cultural, and ethnic needs of the patient population, as well as input received from patients and patient group; Be updated periodically; and be reviewed by the facility’s dietitian or other clinically qualified nutrition professional for nutritional adequacy. 42 C.F.R. §483.60 (c)
• The facility must ensure that each patient receives and the facility provides food prepared by methods that conserve nutritive value, flavor, and appearance; 42 C.F.R. §483.60 (d)(1)
• 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)
• The facility must ensure that food is prepared in a form designed to meet individual needs and accommodates patient allergies, intolerances, and preferences; 42 C.F.R. §483.60 (d)(3)(4)
• The facility must ensure appealing food options of similar nutritive value to patients who choose not to eat food that is initially served or who request a different meal choice; 42 C.F.R. §483.60 (d)(5) and
• 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)
• 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)
• The facility must ensure that there are no more than 14 hours between a substantial evening meal and breakfast the following day, except when a nourishing snack is served at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast the following day if a patient group agrees to this meal span. 42 C.F.R. §483.60 (f)(2)
• The facility must ensure that suitable, nourishing alternative meals and snacks are provided to patients who want to eat at non-traditional times or outside of scheduled meal service times, consistent with the patient plan of care. 42 C.F.R. §483.60 (f)(3)
• 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)

The Problem of Nursing Home Neglect Causing Dehydration and Malnutrition

Despite these clear and specific regulatory mandates, nursing homes too often fail to protect patients’ nutritional and hydrational status. A 2000 Atlanta Ombudsman report revealed that when patients were asked the question, If you could do one thing to change this nursing home, what would it be?, “Nutrition Concerns” was the second most frequent of the top three concerns. (The top response was “More Help;” the third, “Better Quality Staff.”)(Atlanta Long-Term Care Ombudsman Program, 2000).
One study found that up to 85% (a range of 23 – 85%) of nursing home patients are malnourished (Thomas et al., 2000; Silver et al., 1988; Shaver et al, 1980; Burger et al., 2000). For example, a prevalence of 54% malnutrition was found in one Baltimore long-term care facility (Thomas et al., 1991).
Lawmakers 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.”

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.

How Does Dehydration and Malnutrition Happen?

A variety of factors can play a role in malnutrition and weight loss; however, it is undeniably true that nursing homes too often fail to ensure that patients are receiving the care they should be receiving, and often, the reason is that the facility has an insufficient number of trained and super-vised staff available. Patients who struggle to physically move food from the plate to their mouths because of paralysis, contractures, tremors and other disabilities require staff assistance with eating. If the staff doesn’t provide this assistance because they’re too busy performing other tasks, patients won’t receive the daily nutrition and hydration they need. Similarly, when the nursing staff is too shorthanded to ensure that patients have drinking water available and within reach — as well as assistance with drinking if needed — patients won’t receive adequate hydration.
This harm is preventable. And understaffing is no excuse.
Other preventable factors can play a role, as well. Patients who have missing or ill-fitted dentures or untreated teeth or gum problems often have difficulty meeting their nutritional needs. Even when patients are capable of eating and drinking, other factors within the nursing home staff’s control may negatively impact the patients’ nutrition, such as serving meals that are visibly unappealing, are of poor quality, or served at the wrong temperature. Likewise, an unappealing eating environment can impact a patient’s nutritional intake. For example, too often, incontinent patients are not changed in a timely manner, which needlessly results in foul odors within the facility that diminish patients’ appetites. Other common problems include allowing inadequate time for patients to chew and swallow their food, and failing to assist patients with eating (Basler, 2004).

Sometimes patients don’t receive sufficient hydration because the nursing home staff intentionally and inexcusably withholds fluids in order to avoid having to take the patient to the bathroom or providing incontinence care.

Signs of Weight Loss

It’s important for patients and families to take notice of significant weight loss. The first step is to ensure the patient is being properly weighed on a routine basis. The nursing home is supposed to conduct regular weight checks, but this doesn’t always happen. In some cases, nursing homes document that they checked a patient’s weight when they didn’t.
The chart below suggests parameters that put weight loss into context and may help you deter-mine whether a patient’s weight loss represents a significant change that requires further evaluation and intervention (Centers for Medicare & Medicaid Services, 2017).

Formula for Determining Percentage of Weight Loss: % of body weight loss = (usual weight – actual weight) / (usual weight)  x 100

Symptoms of Dehydration

It’s important to be on the lookout for signs and symptoms of possible dehydration or electrolyte imbalances. Many symptoms of dehydration can be non-specific, and are also associated with other medical conditions. However, the more symptoms present, the more critical it becomes for a physician consider the possibility of dehydration as an underlying issue that may need to be treated.
Symptoms of dehydration include:

• Lethargy
• Confusion
• Decline in function that may be abrupt
• Dry mucus membranes
• Sunken eyes
• Hypotension
• Recent rapid weight loss
• Dry eyes and/or mouth
• Change in mental status
• Fever
• Vomiting
• Small amount of concentrated urine
• Urinary tract infections
• Elevated pulse
• Dizziness
• Falling
• Change in ability to carry out activities of daily living
• Increased combativeness and confusion
• Constipation and/ or fecal impaction

Dehydration and malnutrition are all-too-common, yet preventable, harms. Be watchful and questions the nursing home staff to ensure they’re being vigilant in their responsibilities to ensure adequate hydration and nutrition.

 

Parameters for Evaluating the Significance of Unplanned and Undesired Weight Loss

Interval	Significant Loss	Severe Loss
1 month	5%	Greater than 5%
3 months	7.5 %	Greater than 7.5%
6 months	10%	Greater than 10%

The fluid requirement for older persons without cardiac or renal disease is approximately 30 mL/kg body weight/day.  (2.2 lbs = 1 kg) (American Medical Directions Association, 2009)

Reporting Suspected Abuse

If you suspect that a patient is suffering from dehydration, or otherwise may be a victim of nursing home neglect or abuse, it is imperative that you promptly bring the matter to the attention of the patient’s physician.  The sooner, the better. Be vigilant and persistent if you still have concerns.

In addition, any time you believe that a nursing home patient is being subjected to neglect or abuse, you can and should report this suspected mistreatment to the proper authorities to ensure that the suspected neglect or abuse is properly investigated.  Filing a nursing home complaint is easy. You can find out more information about how to file a nursing home complaint here.  By filing a complaint, you can help protect victims of nursing home neglect/abuse, ensure that any patient at risk of harm is protected, and help ensure that the facility corrects any care deficiencies identified by the state investigators.  You can file the complaint anonymously.

If a loved one has suffered serious injury or death as a result of dehydration, or any other form of patient neglect/abuse, you may also have grounds to file a civil action against those responsible for the nursing home.  Keep in mind, there are deadlines for filing civil cases against nursing homes for patient neglect or abuse.  If you are considering such a claim, you should consult with a qualified nursing home neglect/abuse attorney without delay.

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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.