Failure to Monitor and Document Post-Dialysis Care
Penalty
Summary
The facility failed to ensure appropriate post-dialysis assessment and monitoring for a resident with end stage renal disease who required hemodialysis. The resident's care plan included interventions such as monitoring for signs and symptoms of infection, renal insufficiency, bleeding, and other complications, as well as specific instructions not to draw blood or take blood pressure in the arm with a graft. Despite these interventions, there was no evidence that the resident was assessed or monitored upon return from dialysis on multiple occasions. The dialysis communication form was not immediately retrieved or reviewed by the assigned nurse, and vital signs were not recorded regularly, with the most recent entry being a month prior to the incident. Progress notes for the days the resident returned from dialysis were also missing. Interviews with staff revealed that the nurse assigned to the resident was unfamiliar with the resident and did not receive or review the dialysis communication form. The Director of Nursing confirmed that the form was later found in the resident's wheelchair pocket and acknowledged that the nurse did not monitor the resident or document a progress note after dialysis. The facility's policy required immediate retrieval of the dialysis communication form, assessment of the resident's stability, and documentation in the medical record, none of which were followed in this instance.