Failure to Implement Dialysis Access Site Care
Penalty
Summary
The facility failed to implement appropriate care to prevent potential complications from a dialysis access site for a resident requiring dialysis services. The resident, who undergoes dialysis treatment three times a week through a fistula located over his right bicep, reported that staff occasionally attempted to take blood pressure readings from his right arm, despite his instructions to use his leg. There were no indicators in the resident's room or clinical records to restrict the use of his right arm for blood pressure assessments or blood draws. The deficiency was confirmed during an interview with the Director of Nursing, who acknowledged that the right arm limb restriction was not included in the resident's plan of care until after the surveyor's inquiry. This oversight posed a risk of potential damage to the resident's dialysis fistula. A subsequent observation revealed that a sign was placed above the resident's bed to indicate the restriction, but this was only after the issue was raised by the surveyor.
Plan Of Correction
1. Resident 62 care plan updated, special instructions updated, and order placed not to use right arm for BP, veni-punctures. 2. Currently there are no other dialysis patients in the Center that could be potentially affected by the same deficient practice. 3. DON/Designee will educate nursing staff on 483.25(1), and policy Dialysis. 4. DON/Designee will do an audit weekly x4 and monthly x3 to assure that all new dialysis residents have appropriate orders and care plans for affected limbs related to fistulas. Results of the inspections will be submitted to the QAPI team. 5. Date of compliance 1/30/25.