Case Types
Dehydration
Elderly people are more likely to suffer from dehydration than younger people. Dehydration occurs when the body has too little fluids because more fluids are lost than are taken in. Dehydration can result in an overall decline in health, headaches, urinary tract infections, constipation, bedsores, kidney damage, and death.
Dehydration is particularly problematic at nursing homes because nursing homes control the amount and types of fluids that are available to residents. Dehydration in nursing home residents is often a sign of abuse and neglect.
What Causes Dehydration at Nursing Homes?
- Understaffing: Studies have confirmed that understaffing and a lack of supervision is a primary cause of dehydration in nursing homes. Many residents require supervision and encouragement with drinking fluids. If there are not enough staff to assist residents, residents who need assistance simply do not get the help they need, causing them to become dehydrated.
- Vomiting and diarrhea from infections: Many infections cause diarrhea and/or vomiting. These infections include viral and bacterial gastrointestinal infections and a form of colitis called c. diff. As the body’s immune system attempts to rid itself of the infection through vomiting and diarrhea, more water is being lost than is being taken.
- Medications: Certain prescription and over the counter medicines can cause dehydration, including potassium, migraine medications containing caffeine, many diabetes medications, and certain mental health medications. Other medications, including some cancer medications, can cause excessive sweating leading to dehydration.
- Dementia: People with dementia often are unable to communicate that they are thirsty. They also sometimes are unable to recognize that they are thirsty. This leads to them getting insufficient fluid intake.
Diuretics: Diuretics, like Lasix and Bumex, are often prescribed for people who have heart failure. These medications work by flushing fluids that have built up from the body. This relieves stress on the heart. However, because they force the body to shed fluids, they can cause dehydration.
- Laxatives: Laxatives are often given to nursing home residents because they are constipated. Constipation may actually be a sign of dehydration that the nursing home should be monitoring. In addition, the laxatives can increase the risk of dehydration, particularly in the elderly.
- Infections and injuries to the mouth: Anything that causes oral pain or painful swallowing can cause dehydration. This can be due to an infection causing a sore throat or mouth, poor dentition, or an injury.
- Difficulty swallowing: Swallowing difficulties are called dysphagia. Many patients have dysphagia after a brain injury or stroke or as a result of the natural aging process. Patients with dysphagia are at a high risk of becoming dehydrated because they have a difficult time ingesting fluids.
- Thickened liquids: Many nursing home residents are ordered to have their liquids thickened. This is based on a somewhat outdated belief that it is safer for people with swallowing disorders to drink liquids that have been thickened than it is for them to drink regular water. These liquids are thickened by mixing them with a substance that is similar to cornstarch. The liquids become the consistency of nectar or honey. As you might imagine, water and other liquids thickened with a cornstarch-like substance is not appetizing. As a consequence, dehydration is a known risk for patients on thickened liquids.
What are the Signs of Dehydration?
Because dehydration is so dangerous for the elderly, nursing homes and their staff are required to look for signs of dehydration. As dehydration worsens, the risk of permanent injury increases. So, nursing homes must recognize the warning signs of dehydration early.
Early Signs of Dehydration
Mild to moderate dehydration can usually be reversed by drinking fluids, like water, juice, or sports drinks. The early signs of dehydration include:
- Dry mouth
- Dry cough
- Headache
- Constipation
- Swelling of the extremities, especially feet
- Low blood pressure
- Muscle cramping
- Rapid heart rate
- Dark colored urine
- Difficulty walking
Late Signs of Dehydration
Late signs of dehydration are more dramatic than early signs. They indicate a serious medical condition that likely requires hospitalization. These signs include:
- Fever, over 102 degrees
- Dry skin
- Decrease in skin turgor (when the skin on the back of the hand is lifted, it does not return to its normal position immediately and stays lifted)
- Passing out or fainting
- Mental status changes, including confusion, slurred speech, delirium, or hallucinations
- Seizures
- Muscle twitching
What are the Complications of Dehydration?
Dehydration can cause a number of serious and sometimes irreversible complications. Some of these complications include:
- Urinary tract infections
- Kidney stones
- Acute kidney injury and kidney failure
- Injuries from falling, including broken bones and brain injuries
- Oral infections
- Brain swelling
- Coma
- Seizures due to electrolyte imbalances
- Bedsores
- Hypovolemic shock
- Death
How is Nursing Home Dehydration Treated?
The initial treatment for dehydration is to rehydrate the resident and restore the electrolyte balance. Electrolytes are essential minerals–like potassium, sodium, and calcium. They are essential for the body and organs to function properly.
For mild to moderate dehydration, the treatment is likely as simple as making sure the resident drinks water and ingests enough electrolytes to restore the electrolyte balance. Most sports drinks or Pedialyte contain enough electrolytes to restore the appropriate balance.
For more severe forms of dehydration, intravenous (IV) fluid resuscitation is usually needed. IV fluids are made of a saline solution made of vital vitamins and minerals. This solution helps restore the electrolyte balance. Unlike drinking water, IV fluids assure that 100% of the fluids are absorbed by the body. If you are severely dehydrated, you could drink cups of water all day and never feel hydrated.
Additional treatment may be needed in an outpatient or hospital setting for injuries caused by severe dehydration. For example, if a person suffers hypovolemic shock from severe dehydration, they will require not only IV hydration but medicine to increase the amount of blood pumped out of the heart. If a person suffers a urinary tract or oral infection because of dehydration, that will need to be treated with antibiotics. Any injuries suffered in a fall will also need to be treated medically.
How do Nursing Homes Prevent Dehydration?
Nursing homes are obligated to provide an environment and care that maximizes the overall health and well-being of their residents. When it comes to dehydration, the mandatory steps include:
- Assess the risk of dehydration: Nursing homes are required to perform initial assessments on residents when they are admitted to the nursing home. They are also required to complete these assessments whenever the resident has any signs of a change in condition. The nursing home must also reassess the resident at least every 91 days. This includes assessing any risk factors that a nursing home resident has that could cause dehydration. Only once you know why a resident is at risk of dehydration, can you take steps to prevent dehydration.
- Prevent dehydration: Once a nursing home has thoroughly assessed the resident and determined their risk for dehydration, they must implement a plan to prevent dehydration. This could include encouraging the resident to drink throughout the day. For a resident who needs supervision or physical assistance with drinking, it means having enough qualified staff to provide whatever level of assistance they need. Offer different types of drinks throughout the day and provide drinks that the resident prefers. Provide foods that have a high liquid content, such as gravies, yogurts, and fruits. Nursing homes can provide sweets called Jelly Drops that are designed to help dementia patients drink more water. Nursing homes are also required to monitor the intake of fluid. If a nursing home is doing their job, they should know how much fluid a resident is drinking throughout the day. They can compare with the amount of fluid a person requires daily to prevent dehydration.
- Identify any signs of dehydration: Nursing home staff must be thoroughly trained to identify the signs and symptoms of early dehydration. If there are enough qualified staff, then identifying the early signs of dehydration should not be difficult.
- Treat the dehydration: Early detection and treatment of dehydration is key. Early dehydration is almost always treatable with simple rehydration. More severe dehydration can lead to permanent injuries. Nursing homes must spot the early signs of dehydration and act accordingly.
- Determine the cause of the dehydration: It is not enough to treat a resident’s dehydration. A nursing home performs what is called a root cause analysis. A root cause analysis determines what caused the dehydration. Only once you know what caused the dehydration, can you implement a plan to correct the problem and prevent future dehydration.
If a nursing home fails to take any of these steps, then they are potentially liable for abuse and neglect.
Representative Cases
Stephen
Stephen was a 69-year-old man with a history of schizophrenia and a traumatic brain injury. He was blind and required staff to provide food and water for him. Over the course of months, he demonstrated signs of severe dehydration. The nursing staff recorded his fluid intake. However, on no days did he drink the recommended amount of water. On many days, he drank no water at all. He was documented to be so thirsty that he drank out of toilets and sinks in search of water. The jury awarded $26,000,000.
Ed
Ed was an 89-year-old man who moved into an assisted living facility in November. By January, his family was complaining and emailing the facility that he needed more care and was not doing well. The assisted living facility did not increase the amount of care provided. Ed lost weight and became lethargic. He was sent to the hospital where he was diagnosed with a severe urinary tract infection, dehydration, and malnutrition. He required 5 liters of fluid to restore his hydration. Sadly, the urinary tract infection caused by the dehydration was so severe that he died.
Jack
Jack was an 84-year-old resident of a nursing home. He had previously lived at home before falling and injuring his leg. He was admitted to a nursing home for rehabilitation to allow his leg to heal. While at the nursing home, his family became concerned about his care. He was losing weight, becoming weak, and suffering from stomach cramping. He then began experiencing diarrhea. After doing online research, his family became concerned that he was suffering from an infection called clostridium difficile (c diff.). The nursing home assured his family that he did not have c diff. The nursing home said he was suffering from a mildly irritated stomach. Two days later, he was taken to the hospital where he was diagnosed with c. diff. The infection had progressed to cause a systemic illness called sepsis. He died from organ failure caused by untreated c. diff. Upon arriving at the hospital, he was so dehydrated that he had lost 15 pounds of water that had to be replaced by IV fluid resuscitation. The jury returned a verdict for $5,000,000. This was double the highest recorded verdict in the county’s history.
Gloria
Gloria was a 92-year-old resident of a nursing home. Over a period of days to weeks, she began demonstrating signs of dehydration. These signs included darkened urine, mental status changes, and kidney damage. As a result of the severe dehydration, she developed a urinary tract infection that was not treated. The urinary tract infection caused her to develop sepsis causing her death.
How Much is My Nursing Home Dehydration Case Worth?
Every case is unique and has to be evaluated on its specific facts. The only way to determine the value of your nursing home dehydration case is to begin an investigation.
