Failure to Consistently Assess AVF Shunt for Dialysis Resident
Penalty
Summary
The facility failed to ensure that a resident requiring dialysis care received services consistent with professional standards of practice, specifically regarding the assessment of the resident's arteriovenous fistula (AVF) shunt. The facility's policy required daily assessment of the AVF, including checking for color, temperature, radial pulse, and patency by palpating for a thrill or auscultating for a bruit, with documentation every shift. However, review of the resident's electronic medical record, medication administration record, and treatment administration record revealed no documentation that the AVF was assessed for patency, thrill, or bruit from the time of readmission. There was also no physician's order in place to monitor the shunt for patency, and the care plan intervention to check the shunt twice daily was not consistently followed. The resident in question had a history of chronic obstructive pulmonary disease and renal failure, requiring hemodialysis three times a week. Staff interviews confirmed that the AVF was not assessed as required, and the necessary physician's order was missing following the resident's readmission. The minimum data set (MDS) assessment also failed to indicate that the resident was receiving hemodialysis, despite this being the case. Documentation showed that the AVF was only checked on a few isolated dates, rather than consistently twice daily as required by the care plan and facility policy.