Failure to Ensure Complete Dialysis Access Site Assessment and Documentation
Penalty
Summary
The facility failed to provide appropriate dialysis care and services for a resident receiving hemodialysis by not ensuring proper assessment and documentation of the resident's right upper arm arteriovenous (AV) shunt vascular access, as required by facility policy. Record reviews showed that the resident, who had end stage renal disease and was dependent on dialysis, had multiple instances where dialysis communication records from the dialysis center were incomplete. These records, covering several dates, lacked full documentation of the dialysis access site assessment, including checks for signs and symptoms of infection, and whether bruit and thrill were present. Interviews with the Assistant Directors of Nursing confirmed that the incomplete documentation could cause confusion in care delivery and that the receiving nursing staff should have contacted the dialysis center when records were incomplete. The facility's policy required regular written communication from the dialysis provider, including vital signs, pre- and post-dialysis weight, and any problems encountered, but this was not consistently documented for the resident in question.