Inadequate Documentation and Oversight of Dialysis Care
Penalty
Summary
The facility failed to ensure that a resident requiring dialysis received services consistent with professional standards of practice. Specifically, there was no documented evidence of consistent assessment and oversight before, during, and after dialysis treatment for a resident who received hemodialysis treatments at a community-based dialysis center. The facility's policy required monitoring of residents receiving hemodialysis, including checking for the presence of thrill and bruit at the arteriovenous fistula daily and documenting the resident's condition, including vital signs and post-dialysis weight. However, the documentation was inconsistent, and there were no pre and post-dialysis notes in the progress notes for several dates in January 2025. Interviews with facility staff revealed that the communication book used to document dialysis treatments was not consistently used, and the dialysis center staff did not write in the book. The Assistant Director of Nursing was unaware that the dialysis center should have been writing in the communication book and noted that the facility staff were expected to check the resident pre and post-dialysis and document a progress note. The Director of Nursing stated that the use of the communication book had stopped during COVID-19, and they were not aware it was still not being used. The dialysis center's Registered Nurse Manager reported poor communication with the facility, with calls often going unanswered and documents not being consistently sent to the facility.
Plan Of Correction
Plan of Correction: Approved March 10, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. What corrective action will be accomplished for the resident affected by the deficient practice? The was no harm to the resident affected by the deficient practice. The [MEDICAL TREATMENT] communicated with facility via email or telephone when there are changes. The [MEDICAL TREATMENT] center was contacted and has agreed to update resident's notebook pre and post [MEDICAL TREATMENT] to keep facility update with resident care while at [MEDICAL TREATMENT]. 2. How will The New Jewish Home(NAME) Neuman identify other residents having the potential to be affected by the same deficient practice? A facility wide audit will be conducted to identify whether there any other residents receiving [MEDICAL TREATMENT]. There are no other residents currently receiving [MEDICAL TREATMENT]. All newly admitted [MEDICAL TREATMENT] residents will receive a care plan for [MEDICAL TREATMENT] to ensure consistent monitoring. 3. What measures will be put into place or systemic changes made to ensure the deficient practice will not recur? To prevent the deficient practice all nursing staff will receive training and education on the [MEDICAL TREATMENT] policy to ensure that the appropriate assessment and oversight occurs pre-and post [MEDICAL TREATMENT]. This education will include review and update of the resident care plan, required documentation from the community [MEDICAL TREATMENT] center pre and post [MEDICAL TREATMENT] and required documentation by nursing staff for residents on [MEDICAL TREATMENT] including assessment of the arteriovenous fistula. This training will be completed by the Nurse Educator and/or designee. Review and update all [MEDICAL TREATMENT] care plan quarterly and as needed based on changes. Review residents on [MEDICAL TREATMENT] documentation three times weekly on [MEDICAL TREATMENT] days and provide real time remediation as needed. Identify a designated liaison nurse to oversee [MEDICAL TREATMENT] communication and documentation compliance. Nursing supervisor/Nurse Manager and or designee will review resident communication book three times weekly to ensure pre and post [MEDICAL TREATMENT] documentation is completed. 4. How will The New Jewish Home(NAME) Neuman monitor its corrective action to ensure the deficient practice being corrected will not recur? Director of Nursing and/or designee will conduct weekly audits of [MEDICAL TREATMENT] communication and documentation for one month. Results of audits will be reported to the QAPI Committee monthly by the Director of Nursing/Designees for 3 months to the QAPI committee for action as appropriate.