EL MONTE, CA - A resident at The Gardens of El Monte required emergency hospitalization with life-threatening dehydration after nursing staff failed to monitor fluid intake for over two weeks, despite care plans specifically calling for hydration oversight.
Critical Medical Emergency
On June 1, 2024, emergency responders transported the resident to Greater El Monte Community Hospital after staff discovered them with altered consciousness, a dangerously low heart rate of 28 beats per minute, and oxygen saturation levels of just 72 percent. Normal oxygen saturation ranges from 96 to 100 percent.
Hospital tests revealed the resident's blood sodium level had reached 169 millimoles per liter - a critically dangerous level that indicated severe dehydration. Normal sodium levels range between 135 and 145 mmol/L.
"That kind of sodium level was a dangerously high level," said the attending physician at Greater El Monte Community Hospital during the federal inspection. The doctor stated the resident was dehydrated, emaciated, unable to answer questions, and required aggressive intravenous fluid treatment.
Understanding Hypernatremia Risks
Hypernatremia occurs when blood sodium concentrations become dangerously elevated, typically due to inadequate fluid intake or excessive fluid loss. This condition poses serious health risks including brain cell dehydration, seizures, and potential coma.
The resident's sodium level of 169 mmol/L represented a medical emergency. Hypernatremia at this level can cause cellular dysfunction throughout the body and requires immediate medical intervention to prevent permanent organ damage or death.
"The resident's sodium level indicated that the resident had not received adequate hydration and nutrition for at least a week," the hospital physician told federal inspectors.
Documented Care Plan Failures
Federal inspectors found that facility staff had created specific care plans addressing the resident's dehydration risk on May 16, 2024. These plans required staff to monitor fluid intake, provide assistance during meals, and watch for dehydration symptoms including dry mouth, fever, poor skin elasticity, and mental status changes.
The resident required between 1,950 and 2,040 milliliters of fluid daily to maintain proper hydration, according to the facility's registered dietician assessment completed May 21, 2024.
However, intake records showed the resident consistently received inadequate fluids: - May 16: 120 mL - May 17: 350 mL - May 21: 360 mL - May 24: 180 mL - May 29: 200 mL - May 31: 280 mL
Most daily totals fell far below the required minimum, with some days showing less than 10 percent of needed fluid intake.
Staff Communication Breakdown
Federal inspectors discovered significant communication failures between different levels of nursing staff. The registered dietician acknowledged not reviewing the resident's documented fluid intake between May 16 and May 21, despite completing a nutrition assessment during this period.
"I could have caught that the resident was not drinking enough fluids and talked to the nursing staff," the dietician told inspectors.
Licensed practical nurses interviewed during the inspection stated they were unaware of the resident's hypernatremia history and daily fluid requirements. Certified nursing assistants responsible for documenting intake reported the resident needed extensive encouragement to drink but failed to communicate these struggles to licensed nurses.
One nursing assistant told inspectors she was "not sure if the resident drank enough fluids during her shift and did not know where to find out how much fluids the resident needed."
Industry Standards Violated
Nursing home regulations require facilities to ensure residents receive adequate nutrition and hydration to maintain health and prevent medical complications. Facilities must develop individualized care plans and ensure staff implementation of those plans.
The facility's own policies, revised in March 2021, stated that residents should receive "an adequate amount of fluid during the 24-hour day in accordance with each resident's individual needs." The policies also required weekly evaluation of fluid intake records by licensed nurses.
Medical Consequences
The registered dietician explained to federal inspectors that dehydration can worsen multiple medical conditions including urinary tract infections, sepsis, and kidney damage. For residents with existing kidney disease, like this resident, adequate hydration becomes even more critical for preventing further organ damage.
The resident's hospitalization required aggressive IV fluid therapy to restore proper electrolyte balance and prevent additional complications from the severe hypernatremia.
This violation was classified as causing "actual harm" to residents, indicating that the facility's failures directly resulted in negative health outcomes requiring medical intervention.
The Gardens of El Monte must submit a plan of correction to address these deficiencies and prevent similar incidents from occurring with other residents.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Gardens of El Monte from 2024-06-17 including all violations, facility responses, and corrective action plans.
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