Failure to Complete and Document Post-Dialysis Assessments
Penalty
Summary
A resident with end-stage renal disease and dependent on dialysis was admitted to the facility and had physician orders specifying dialysis treatments three times weekly, with a requirement for post-dialysis assessments upon return to the facility. The resident's medical record review showed that the last documented post-dialysis assessment was completed on 3/24/25, with no evidence of assessments on thirteen subsequent dialysis dates. The resident confirmed that nursing staff did not assess them after returning from dialysis. Interviews with staff revealed that the agency RN reviewed paperwork and entered new orders upon the resident's return from dialysis but did not consistently document or perform post-dialysis assessments. The LPN Unit Manager acknowledged the lack of documentation for the required assessments and stated that nursing staff were expected to assess the resident, including the dialysis access site, and document these findings after each dialysis session.