Failure to Assess Pre- and Post-Dialysis Vital Signs
Penalty
Summary
The facility failed to ensure that vital signs were assessed before and after dialysis for a resident with multiple chronic conditions, including chronic kidney disease, atrial fibrillation, coronary artery disease, diabetes mellitus, and hypertension. The resident's care plan included interventions for monitoring the dialysis access site but did not address the need for pre- and post-dialysis vital sign assessments. Documentation for April 2025 did not show any record of vital sign assessments before or after dialysis sessions. Interviews with the resident and staff revealed that vital signs were not routinely taken upon the resident's return from dialysis, and staff were unaware of any requirement to do so. The trained medication aide confirmed that no assessment was performed after dialysis, and the registered nurse stated that only the dialysis site was checked, with vital signs being taken at the dialysis facility. The director of nursing acknowledged that pre- and post-dialysis vital signs should be taken to monitor for complications, but this was not reflected in practice or in the facility's dialysis policy, which did not address vital sign assessments.