Inaccurate Dialysis Care Plan for Resident
Penalty
Summary
The facility failed to ensure the accuracy of a care plan for a resident who was undergoing dialysis. The resident, diagnosed with dependence on renal dialysis and end-stage renal disease, was observed returning from dialysis, and the transportation staff communicated this to the charge nurse. The care plan, dated the same day, included several standard dialysis-related orders, such as monitoring for complications, scheduling dialysis visits, and encouraging attendance at appointments. However, the care plan inaccurately referenced an arteriovenous fistula (AVF) when the resident actually had a port in the left chest and had just started dialysis treatments. The Director of Nursing (DON) confirmed that the resident had a port and not an AVF, and the MDS coordinator admitted to entering standard dialysis orders instead of person-centered information specific to the resident's current condition. This discrepancy in the care plan indicates a lack of accurate, individualized care planning for the resident's dialysis needs, which could potentially impact the quality of care provided to the resident.