Failure to Ensure Accurate Dialysis Communication and Adherence to Fluid Restriction Orders
Penalty
Summary
The facility failed to ensure accurate communication and documentation between its staff and the dialysis provider for a resident with end stage renal disease (ESRD) and heart failure. The facility's policy required licensed nurses to complete pre- and post-dialysis assessments and ensure the Dialysis Communication forms were filled out and sent with the resident. However, multiple instances were identified where these forms were incomplete or missing critical information such as vital signs, dialysis site assessment, nurse signatures, and dates. Interviews with staff confirmed that this was an ongoing issue, and the facility had not provided staff training related to dialysis care. Additionally, the facility did not follow the resident's care plan and physician orders regarding fluid restriction. The resident was ordered a 1000 ml daily fluid restriction, with specific instructions for kitchen and nursing staff on fluid allocation and requirements to notify the care team if the restriction was not adhered to. Despite these orders, documentation showed the resident frequently exceeded the fluid limit, and there was no evidence that staff notified the appropriate personnel or monitored for signs of fluid overload as required. Observations revealed that the resident often had multiple beverages at the bedside, including large cups of water, and there was no signage indicating a fluid restriction. Staff interviews further revealed a lack of awareness regarding the resident's fluid restriction and care needs, such as the use of compression stockings for edema. Some staff provided fluids upon request without knowledge of the restriction, and others were unaware of the required monitoring for swelling. The resident reported attending dialysis more frequently due to fluid overload and not consistently receiving compression socks. Documentation and staff statements confirmed that the care plan and physician orders were not consistently followed, and assessments for fluid overload were not completed as required.