Failure to Document Dialysis Access Assessment
Penalty
Summary
The facility failed to ensure a physician's order was in place to properly assess a resident's dialysis access site. This deficiency was identified for a resident who was dependent on renal dialysis and had a recent medical emergency involving their dialysis shunt, which started to bleed, necessitating emergency surgery. Upon review, it was found that the resident's medical records did not include a physician's order to assess the dialysis access site, nor were there any documented interventions in the individualized comprehensive care plan to monitor or assess the site. Further investigation revealed that the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for November and December 2024 did not show any documentation of the dialysis site being assessed or monitored by the nursing staff. Interviews with the nursing staff, including the Licensed Practical Nurse/Unit Manager and another LPN, confirmed the presence of an arteriovenous fistula (AVF) in the resident's arm, but also revealed that assessments were not documented. The Director of Nursing acknowledged the lack of documentation and confirmed that there was no physician's order for assessing the dialysis access, highlighting a lapse in following the facility's Hemodialysis policy.
Plan Of Correction
1. Resident affected by deficient practice: The facility failed to ensure a physician's order was in place to properly assess a resident's Exec Order 26.4NJ Ex Order 26. site. Order was entered for resident #81 to check for NJERECOR. 2. Identifying other residents who could be affected by the deficient practice: Residents with a dialysis access site have the potential to be affected. Other residents with a dialysis access site were audited with no negative findings noted. 3. Measures or systemic changes to ensure that the deficiencies will not recur: Licensed Nurses in-serviced on the policy/process of resident requiring dialysis to include assessing bruit and thrill by Assistant Director of Nursing. 4. Monitoring the continued effectiveness of the systemic change: Unit Manager/designee will audit up to four dialysis resident's charts and ensure orders/care plan is in place weekly x 4 then monthly x 2. Results of the audit will be reviewed at the Monthly Quality Assurance Meeting and Quarterly over the duration of the audit process to ensure compliance and reassessed for further action.