Failure to Monitor Dialysis Access Leads to Harm
Penalty
Summary
The facility failed to ensure that a resident requiring dialysis received services consistent with professional standards of practice. The resident, identified as R104, was admitted with end-stage renal disease and required hemodialysis three times a week. After a surgical procedure on the resident's right arm fistula, which is used for dialysis access, the facility did not obtain the attending physician's orders for the care and monitoring of the fistula upon the resident's return from the hospital. Nursing documentation revealed that the resident's right arm was swollen and showed signs of infection, yet there was no evidence that the resident's physician was notified of these ongoing issues. The facility's policy on hemodialysis catheter access and care emphasizes the importance of preventing infection and maintaining catheter patency. However, the facility did not adhere to these guidelines, as evidenced by the lack of regular assessments and documentation of the resident's condition. The resident's nursing notes indicated ongoing erythema and swelling at the surgical site, but the facility failed to document any assessment or evaluation of the surgical wound from December 6 to December 9, 2024. Additionally, there was incomplete communication between the facility and the dialysis center, with missing or incomplete data in the dialysis communication books. As a result of these deficiencies, the resident experienced actual harm, requiring an emergent transfer to the hospital due to a swollen, infected fistula with purulent drainage and the development of a non-occlusive right brachial deep vein thrombosis. The facility's failure to properly monitor and assess the resident's condition led to this adverse outcome, highlighting significant lapses in the care and communication processes related to the resident's dialysis treatment.
Plan Of Correction
Resident 104 orders were reviewed and physician orders for monitoring of AV site are present. Residents currently receiving dialysis services orders were reviewed for appropriate monitoring of dialysis sites. Dialysis representative re-educated licensed staff on monitoring of dialysis sites and complications of dialysis to observe for. Unit manager/designee will complete random audits of residents currently receiving dialysis services to ensure monitoring of dialysis site weekly x4 then monthly x2 and report findings to QAPI committee monthly.