Failure to Complete Post Dialysis Assessment Documentation
Penalty
Summary
The facility failed to follow its policy and procedure for the care and assessment of a resident requiring hemodialysis. Specifically, after a resident with end stage renal disease and dependence on dialysis returned from a scheduled dialysis treatment, the required post dialysis assessment form was not completed. The form, which is intended to document the resident's status and monitor for complications such as unstable vital signs or bleeding at the catheter site, was left blank. This omission was confirmed during a review of the resident's records and through interviews with both a Licensed Vocational Nurse and the Director of Nursing, who acknowledged that the assessment should have been performed and documented. The resident involved had a history of end stage renal disease, was cognitively intact, and had an active order for dialysis three times per week. The facility's policy required nurses to document observations post dialysis every shift, but this was not done on the specified date. As a result, there was no documentation of the resident's baseline vital signs or monitoring of the access site following dialysis, as required by facility policy.
Plan Of Correction
F698: Dialysis CORRECTIVE ACTION On 3/8/25, resident 62 was assessed for any negative effects from not having the post dialysis assessment by the DON. No negative effects were noted. OTHER RESIDENTS AFFECTED IDENTIFICATION On 3/7/2025, DON reviewed all dialysis residents' post dialysis forms and found that 1 other resident had incomplete pre/post dialysis form. The resident was assessed for any negative effects from not having the post dialysis assessment by the DON. No negative effects were noted. MEASURES AND SYSTEMIC CHANGES On 3/25/2025, the DON provided an in-service to Licensed Nurses regarding the importance of performing post dialysis assessments. The completion of post dialysis assessments is emphasized. DON/Designee will review dialysis residents' pre/post dialysis assessments during the daily (Monday to Friday) clinical meeting for completion and will correct them as needed. MONITORING PERFORMANCE DON/Designee will report findings and trends to the monthly QAA meeting for further recommendations for 3 months or until substantial compliance is met. OTHER RESIDENTS AFFECTED IDENTIFICATION On 3/7/2025, DON reviewed all dialysis residents' post dialysis forms and found that 1 other resident had incomplete pre/post dialysis form. The resident was assessed for any negative effects from not having the post dialysis assessment by the DON. No negative effects were noted. MEASURES AND SYSTEMIC CHANGES On 3/25/2025, the DON provided an in-service to Licensed Nurses regarding the importance of performing post dialysis assessments. The completion of post dialysis assessments is emphasized. DON/Designee will review dialysis residents' pre/post dialysis assessments during the daily (Monday to Friday) clinical meeting for completion and will correct them as needed. MONITORING PERFORMANCE DON/Designee will report findings and trends to the monthly QAA meeting for further recommendations for 3 months or until substantial compliance is met. F699: Trauma informed care