Failure to Monitor and Document Dialysis Access Site
Penalty
Summary
The facility failed to provide appropriate care and monitoring for a resident requiring dialysis, specifically neglecting to accurately assess and monitor the resident's dialysis access site. The resident, who had a history of type 2 diabetes mellitus with chronic kidney disease and was dependent on renal dialysis, had a dialysis access site located in the right chest wall. Despite this, the resident's medical record, including the Minimum Data Set (MDS) and care plan, did not reflect the current dialysis access site or include interventions for its monitoring. Instead, active physician orders and documentation incorrectly referenced a right arm arteriovenous (AV) shunt, which the resident no longer had, as it had been removed approximately three months prior. Observations and interviews confirmed that nursing staff continued to document monitoring of a right arm graft, including assessments for bruit and thrill, even though the resident's access site was in the chest wall and did not require such assessments. There was no documented monitoring of the actual chest wall dialysis access site, and the care plan lacked any interventions related to this site. Both the LPN and the interim Director of Nursing acknowledged the absence of appropriate monitoring and documentation for the resident's current dialysis access site.