Failure to Provide Safe Dialysis Care
Summary
The facility failed to provide appropriate dialysis care for a resident who required such services, as evidenced by multiple instances of blood pressure being taken in the resident's left arm, where an arteriovenous (AV) fistula was located. This practice is against professional standards as it can lead to serious complications such as clots, loss of use of the fistula, and potentially a stroke. The resident's medical records showed several documented instances where blood pressure was taken in the left arm, despite clear orders and care plans indicating that this should not occur. Additionally, the facility did not complete post-dialysis assessments for the resident upon their return from dialysis sessions. The dialysis communication book lacked documentation of these assessments, which are crucial for monitoring the resident's condition and ensuring any complications are promptly addressed. The care plan for the resident included instructions to monitor for signs of infection, edema, and bleeding upon return from dialysis, but these were not consistently followed. Observations revealed that there was no signage in the resident's room or on their person to alert staff about the restricted limb for blood pressure measurements. Interviews with staff, including an LPN and the Director of Nursing, confirmed that the orders and care plan were not adhered to, leading to the deficiency. This oversight placed the resident at immediate risk of serious injury, prompting the state agency to determine the situation as an immediate jeopardy.
Removal Plan
- Resident #9 will be evaluated by the licensed nurse upon return to the facility.
- All dialysis residents have the potential to be affected.
- The Unit Managers/designee conducted an audit for all residents on dialysis with specific B/P orders to be taken and POST dialysis assessment is completed upon return to the facility with any corrective action immediately upon discovery.
- The Order for B/P not to be taken in the Left arm on Resident #9 will be added to the Medication Administration Record in all Capital letters and will be added to the care plan and kardex in capital letters.
- The Director of Nursing(DON)/designee will reeducate all nursing staff with a posttest to validate understanding regarding hemodialysis graft, fistula care, communication, and documentation.
- Verify orders and instructions from hemodialysis facility or hospital, if patient is a new Admission.
- Evaluate access site daily and on completion of hemodialysis (HD) or home hemodialysis (HHD) treatment. Observe for signs of complications.
- Inspect fistula site for decrease or absence of vein dilation.
- Palpate for distal thrill.
- Auscultate for bruit.
- Palpate skin around graft/fistula for warmth.
- Evaluate skin around vascular access noting redness, swelling, local warmth, exudate, tenderness.
- Observe for presence of fever, chills, hypotension and notify physician/advanced practice provider (APP) and hemodialysis facility staff for complications.
- Protect access site from getting wet for several hours after HD or HHD treatment.
- Avoid trauma or treatment procedures in the accessed extremity, such as limiting activity of extremity, blood pressure measurement, venipuncture, injection of any type, use of creams or lotions on the access site.
- Instruct patient to avoid excessive pressure on the extremity or strain and in strengthening exercises to enhance blood flow if permitted by physician/APP and dialysis facility.
- Document location of access site on admission assessment, status of access site in Nurses' notes, status of pulses distal to access area, color and temperature of extremity, presence or absence of pain or numbness, status of bruit and thrill, notification and response of physician/APP and dialysis facility, patient education and family involvement, nursing intervention.
- Center staff will communicate with the certified dialysis facility regarding the ongoing assessment of the patient's condition by monitoring for complications before and after hemodialysis (HD) treatments received at a certified dialysis facility.
- Prior to a patient leaving the Center for HD, a licensed nurse will complete the top portion of the Hemodialysis Communication Record, or the state required form and send with the patient to his/her HD facility visit.
- Following completion of the HD, the dialysis facility nurse should complete and return the form and return it or other communication to the Center with the patient.
- Upon return of the patient to the Center, a licensed nurse will review the certified dialysis facility communication, evaluate/observe the patient, and complete the post-hemodialysis treatment section on the Hemodialysis Communication Record or state required form.
- Notify the certified dialysis facility if the form is not returned with the patient and ask that it be faxed to the Center.
- Document notification of certified dialysis facility regarding return of form or other communication.
- Maintain the Hemodialysis Communication Record or state required form in the patient's medical record.
- Any licensed nurses not available during this time frame will be provided re-education, including post-test and return demonstration by DON/designee prior to the beginning of the next shift to work.
- New Licensed nurses will be provided education, including post-test during orientation by the DON/designee.
- Annual in-servicing will be provided to licensed nurses regarding medication administration.
- The DON/designee will complete medication pass competencies quarterly to ensure physician orders are followed including ensuring B/P's are not taken in restricted arm.
- The Unit Managers (UM)/Designee will conduct observations to ensure all licensed nurses are taking B/P and the licensed nurse is completing the dialysis communication sheets POST dialysis daily across all shifts.
- Results of observations will be reported by the Unit Manager (UM)/designee monthly to the Quality Improvement Committee (QIC) for any additional follow-up and or in-servicing until the issue is resolved, then randomly thereafter as determined by the QIC committee.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Incomplete Dialysis Communication Documentation: The facility failed to fully complete the dialysis communication sheet for a resident receiving dialysis services. An LPN stated staff completed assessments and communication sheets before dialysis and upon return, while the DON said staff were expected to complete the sheets completely. Review showed multiple return-from-dialysis sections were left blank, and no earlier communication sheets were provided.
Failure to Document Post-Dialysis Assessment: A resident with ESRD who received hemodialysis twice weekly returned from treatment and reported staff rarely assessed her afterward or checked her chest port. The RN confirmed a pre- and post-dialysis assessment should have been completed and documented on the Dialysis Communication Form, but no post-dialysis assessment was found in the EMR and there was no evidence the resident refused care.
Incomplete Post-Dialysis Assessment Documentation: A resident with DM, COPD, and dependence on dialysis had repeated missing post-HD assessments on the dialysis communication sheet. The care plan and MD orders included dialysis attendance, AV fistula/graft monitoring, and pre-dialysis weights, but staff stated the resident was to be assessed after returning from dialysis and documented on the communication sheet; however, post-dialysis documentation was absent on many dialysis dates.
A resident with ESRD, DM2, and dependence on dialysis missed a scheduled hemodialysis treatment because transport was not arranged after a hospital return. The resident was observed waiting in the lobby for pickup, and staff later stated the dialysis center had not been updated about the hospitalization. The SSD and RT both acknowledged the facility was responsible for notifying the dialysis center and arranging transport, and the dialysis agreement and dialysis monitoring policy reflected that responsibility.
Failure to Monitor Fluid Restriction for a Resident Receiving Dialysis: A resident with ESRD, dependence on renal dialysis, and pleural effusion had a physician-ordered 1200 ml/day fluid restriction, but the MAR and record review showed no documentation of oral intake monitoring. The RNS stated she could not find intake monitoring documentation and noted the resident also lacked a care plan for the fluid restriction, despite facility P&P requiring intake/output documentation and a plan of care for residents on fluid restrictions.
A resident receiving PD was involved in a procedure where an RN did not perform hand hygiene before donning gloves, entered the room without closing the door, and then put on a mask from the resident’s bedside table while continuing the same procedure. The facility’s PD disconnecting procedure required the door to be closed, a mask to be applied, and hand hygiene to be performed before gloves were applied, and the RN had not received facility training related to the resident’s PD.
Incomplete Dialysis Communication Documentation
Penalty
Summary
The facility failed to complete the dialysis communication sheet for one resident who required dialysis services. The resident had a physician order dated 5/20/2026 for dialysis at a third-party dialysis provider on Tuesday, Thursday, and Saturday, with a 7:00 AM pickup time and 7:30 AM chair time, transported by wheelchair. Review of the resident’s dialysis communication forms showed that the section for facility completion upon return from dialysis was not completed on 8/8/2026, 8/6/2026, 8/4/2026, 8/1/2026, and 7/28/2026, and no other communication sheets were provided prior to 7/28/2026. Staff interviews indicated that an LPN completed assessments and communication sheets before dialysis and upon return, and the DON stated that staff were expected to complete the communication sheets completely and that progress notes would be on the communication sheet. The facility policy titled Clinical Dialysis Management stated that facility personnel will provide information useful or necessary for the resident’s care to the dialysis center as needed.
Failure to Document Post-Dialysis Assessment
Penalty
Summary
The facility failed to complete and document a post-hemodialysis assessment for a resident with end-stage renal disease who received dialysis twice weekly and had intact cognition with no refusal of care documented. The resident’s care plan noted that she returned from dialysis tired, often went straight to her room to nap, and required monitoring for increased fatigue and assistance with activities of daily living and mobility as needed. Her EMR also included orders related to her chest port dressing, including routine dressing changes and sterile care instructions. On the day in question, the resident returned from dialysis and stated that staff rarely assessed her when she came back from treatment and did not check her port. She exposed the chest port during the interview, and the dressing was dry and intact without bleeding or drainage. Review of the resident’s progress notes, evaluation notes, and EMR found no documentation of a post-dialysis assessment, and there was no evidence that she refused the assessment. The nurse on duty confirmed that a pre- and post-dialysis assessment should have been completed and documented on the Dialysis Communication Form, but she could not locate the form for that day and stated she did not recall seeing it when the resident returned.
Incomplete Post-Dialysis Assessment Documentation
Penalty
Summary
Safe, appropriate dialysis care/services were not provided for a resident who required hemodialysis. The resident had diagnoses of DM, COPD, dependence on dialysis, and dependence on supplemental oxygen, and the MDS documented a BIMS score of 15 with dialysis received during the observation period. The care plan included interventions for dialysis attendance, shunt monitoring, blood pressure precautions for the shunt arm, and daily weights, but the dialysis-related documentation was incomplete. The physician orders included dialysis on Monday, Wednesday, and Friday, readiness for dialysis by 10:30 AM, monitoring of the AV fistula/graft site upon return from dialysis, and weighing before dialysis for fluid management. Review of the Dialysis Communication Form from 05/01/2026 through 08/03/2026 revealed 41 dialysis communication sheets, and post-dialysis documentation was missing on 25 dates. The facility’s staff stated the resident would be assessed upon return from dialysis and documented on the dialysis communication sheet, and administrative staff stated the charge nurse was expected to complete and document the post-return assessment. The facility’s Hemodialysis policy stated it would provide care and treatment consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the resident’s goals and preferences.
Missed Dialysis Transport for Resident Requiring Hemodialysis
Penalty
Summary
The facility failed to ensure a resident who required hemodialysis was transported to treatment. Resident #106 was admitted with diagnoses including dependence on renal dialysis, end stage renal disease, type 2 diabetes mellitus with diabetic neuropathy, and hypertensive heart and chronic kidney disease with heart failure and end stage renal disease. The care plan identified that he was dependent on dialysis and received hemodialysis three times a week. He had a BIMS score of 13, indicating no cognitive impairment, and was dependent on staff for activities of daily living with impaired upper and lower extremities bilaterally. After the resident returned from the hospital, physician orders continued hemodialysis three times weekly with a 6:15 A.M. pickup time and instruction to be in the lobby at 5:15 A.M. On the morning of the missed treatment, the resident was observed waiting in his wheelchair in the lobby and later stated he was waiting for dialysis transport. Staff later told him he had missed the appointment because transportation had not been set up. The SSD stated it was the facility's responsibility to call and alert the dialysis center of updates, including hospitalizations. The RT stated the dialysis transport was automatic, but when the resident transferred to the hospital the facility did not update the dialysis center, and the center stopped coming after unsuccessful pickup attempts. The facility's dialysis transfer agreement stated it was responsible for arranging transportation to and from the dialysis center, and the dialysis monitoring policy stated the facility would maintain the safety and health of residents receiving dialysis services.
Failure to Monitor Fluid Restriction for a Resident Receiving Dialysis
Penalty
Summary
The facility failed to monitor the fluid restriction for Resident 10, who was admitted and readmitted to the facility with diagnoses including ESRD, dependence on renal dialysis, and pleural effusion. The resident’s MDS dated 6/26/2026 indicated moderate cognitive impairment and dependence for multiple activities of daily living, with setup or clean-up assistance needed for eating and oral hygiene. A physician order dated 7/10/2026 specified a fluid restriction of 1200 ml per day, but during review of the MAR on 7/23/2026, there was no documentation of the resident’s oral intake to show that the restriction was being monitored. The RNS stated she could not find any documentation of oral intake monitoring and also stated the resident did not have a care plan reflecting the 1200 ml fluid restriction. The facility’s P&P for Fluid Restriction required intake and output documentation and a plan of care for residents on fluid restrictions, and the Dialysis Management P&P stated that diet and fluid restrictions would be followed as ordered and documented in the medical record.
Failure to Follow PD Disconnect Procedure
Penalty
Summary
The facility failed to implement care consistent with professional standards of practice to prevent potential complications from a dialysis access site for one resident receiving peritoneal dialysis. The facility’s procedure for disconnecting PD directed staff to close the resident’s door, apply a mask, and then wash hands and apply gloves before accessing the PD port. During observation of the resident’s PD disconnecting procedure, a registered nurse placed gloves on without performing hand hygiene, entered the resident’s room without closing the door, and then applied a mask from the resident’s bedside table while continuing the procedure with the same gloves. The record also showed that the nurse had not received any facility training related to the resident’s PD.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release October 8, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.