Incomplete Dialysis Documentation for Resident
Penalty
Summary
The facility failed to ensure that a resident requiring dialysis received care consistent with professional standards. Specifically, the facility did not complete the dialysis communication forms for the resident on two occasions, leaving vital information such as post-dialysis vitals, assessment for bruit or thrill, and checks for infection or bleeding unrecorded. This oversight was noted for a resident with a history of anoxic brain injury, end-stage renal disease, and type 2 diabetes mellitus with diabetic neuropathy, who was moderately impaired in cognition and required regular dialysis. Interviews with the LVN and the DON revealed that the nursing staff was expected to assess residents before and after dialysis, including taking vital signs and documenting them on the communication form. However, the LVN admitted to forgetting to document the vitals on one occasion, and the form was left blank on another. The facility's policy emphasized the importance of monitoring the dialysis access site for infection and patency, yet these assessments were not documented as required, potentially compromising the resident's care.