Inadequate Dialysis Care and Communication
Penalty
Summary
The facility failed to provide safe and appropriate dialysis care for a resident with end-stage renal disease (ESRD) who required hemodialysis. The resident, who had moderately impaired cognition, reported that staff did not take vital signs or check her dialysis site upon her return from dialysis. The resident's care plan required the completion of a dialysis communication tool on dialysis days and a review upon return from dialysis, including monitoring for bruit and thrill at the shunt site. However, the facility did not consistently complete the necessary post-dialysis assessments as outlined in the care plan. The review of the Dialysis Communication Forms revealed that out of six dialysis sessions, only one session had all sections of the form completed. The forms for four sessions lacked post-dialysis assessments, and one form was missing entirely. The Unit Manager confirmed that the forms were not completed as required and acknowledged that the nurses were educated to complete the forms upon the resident's return from dialysis. Despite attempts to contact the dialysis center for missing information, the facility did not maintain adequate communication with the dialysis center, as required by their policy and procedure for hemodialysis.