Failure to Ensure Proper Dialysis Care and Communication
Penalty
Summary
The facility failed to provide appropriate dialysis care for a resident requiring such services, as evidenced by the lack of ongoing monitoring and communication with the dialysis center. Resident #16, who had diagnoses including type II diabetes, end-stage renal disease requiring hemodialysis, and a history of methicillin-resistant staphylococcus aureus, did not receive proper assessments of their dialysis access site upon leaving and returning from hemodialysis. The facility's policy required assessments and communication with the dialysis center, but these were not conducted, and the resident's care plan did not include necessary details about their dialysis care. The facility's records showed discrepancies, such as the incorrect listing of an AV fistula as the resident's access device, when in fact, the resident had a perma-cath in their chest. Nurses documented monitoring of an AV fistula/graft, which the resident did not have, indicating a misunderstanding or misreading of the resident's orders. Additionally, there was no documentation of pre and post-dialysis evaluations in the electronic medical record, and the Dialysis Communication Book intended for communication between the facility and the dialysis center was not utilized. Interviews with staff revealed a lack of clarity and communication regarding the dialysis process. Registered Nurse #2 and the Unit Manager acknowledged the absence of necessary documentation and communication with the dialysis center. The Director of Nursing and the Administrator confirmed that there was no education provided on dialysis access devices or procedures, and they expected better communication and documentation practices. The deficiency highlights a significant gap in the facility's adherence to professional standards of practice for residents requiring dialysis.
Plan Of Correction
Plan of Correction: Approved March 10, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Provider order for ongoing monitoring of [MEDICAL TREATMENT] site for resident #16 was initiated on 2/11/25 including the correct type of [MEDICAL TREATMENT] site (Permacath). Licensed staff on resident unit were counseled regarding accurate and ongoing monitoring of [MEDICAL TREATMENT] sites. Resident #16’s [MEDICAL TREATMENT] communication book was updated with current medication list and advance directives. Unit staff were counseled regarding [MEDICAL TREATMENT] communication book and policy/procedure in relation to utilization of the communication book with each [MEDICAL TREATMENT] appointment. All residents receiving [MEDICAL TREATMENT] have the potential to be affected. A full house review of all residents receiving [MEDICAL TREATMENT] will be completed to ensure that [MEDICAL TREATMENT] sites are correctly identified and have ongoing monitoring. Review will also include [MEDICAL TREATMENT] communication binders. Any issues will be immediately addressed. The [MEDICAL TREATMENT] policy was reviewed by the Regional Director of Clinical Services with no revisions required. All licensed nurses will be re-educated by the RN Educator regarding [MEDICAL TREATMENT] policy and procedures including accurate and ongoing monitoring of [MEDICAL TREATMENT] sites and consistent communication between the facility and [MEDICAL TREATMENT] Centers. Staff included in scheduling and preparing the residents for their appointments will be reeducated on ensuring all binders are sent with the resident to [MEDICAL TREATMENT] with proper paperwork. The RN educator will perform 5 [MEDICAL TREATMENT] audits weekly; audits will ensure accurate and ongoing monitoring of [MEDICAL TREATMENT] sites and consistent communication between the facility and [MEDICAL TREATMENT] Centers. Any issues noted will be immediately addressed. Audit findings will be reviewed monthly by QAPI committee until the committee determines that compliance has been attained. Person Responsible: DON