Failure to Implement Comprehensive Dialysis Care Plan
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident who was dependent on renal dialysis and had end-stage renal disease. The resident was admitted to skilled services for acute kidney failure, but the care plan, dated shortly after admission, lacked documentation related to dialysis treatments, care before or after dialysis, or care of the resident's port. Upon the resident's return from dialysis, transportation staff informed the charge nurse and provided a form from dialysis, but there was no evidence that this information was incorporated into the care plan. Licensed Practical Nurses (LPNs) involved in the resident's care reported entering information from the dialysis form into the computer and acknowledged the presence of a port in the resident's right upper chest. However, the facility did not have a specific care plan policy in place, as reported by one of the LPNs.