Failure to Provide Safe Hemodialysis Care and Enforce Fluid Restriction
Penalty
Summary
Facility staff failed to provide safe and appropriate hemodialysis care for a resident with end stage renal disease who required strict fluid restriction and special precautions for an arteriovenous (AV) shunt. Observations revealed that a full pitcher of water and a large bottle of juice were left at the resident's bedside, despite a physician's order and care plan specifying a 1000 cc per day fluid restriction. There was no sign posted in the resident's room indicating the fluid restriction or specifying which arm had the AV shunt to prevent blood pressure readings, IV access, or laboratory sticks on that arm. Interviews with staff indicated a lack of knowledge regarding the exact fluid restriction amount and inconsistent monitoring of the resident's fluid intake. The resident, who had moderate cognitive impairment and required assistance with daily activities, reported that staff did not measure or limit fluid intake and was unaware of the fluid restriction. Multiple staff members confirmed that fluid intake was not being accurately monitored and that appropriate signage was not in place. The facility's policy required adherence to physician orders and care plans for residents receiving hemodialysis, including not using the AV shunt arm for certain procedures, but these protocols were not followed for this resident.