Failure to Provide Safe Peritoneal Dialysis Care by Qualified Staff
Summary
The facility failed to provide safe and appropriate peritoneal dialysis care for a resident who required such services, resulting in a serious adverse event. The resident, who had a history of sepsis, peritonitis, and dependence on dialysis, was admitted with moderate cognitive impairment and had recently been discharged from the hospital. On the day of the incident, the resident's peritoneal dialysis (PD) cycler was malfunctioning, and staff were unable to resolve the issue. Communication between the facility staff and the dialysis company led to instructions for a manual fill of dialysate fluid, with a specific order for 1.5 liters to be administered manually. Despite the order, the nursing staff involved were not properly trained in manual peritoneal dialysis procedures. The Director of Nursing (DON) was unfamiliar with manual fills and relied on a Registered Nurse (RN) and an LPN, neither of whom had received adequate training for the procedure. Miscommunication and lack of clarity regarding the correct volume to be infused resulted in the entire 2.5-liter bag of dialysate being administered, rather than the ordered 1.5 liters. The staff did not verify the order or ensure proper documentation in the resident's medical record, and there was confusion about who was responsible for the procedure and the amount to be infused. As a result of the over-infusion, the resident developed severe shortness of breath, hypotension, and hypoxemia, requiring emergency transfer to the hospital. Upon arrival, the resident was found to be in acute respiratory distress with significant abdominal distention and was subsequently intubated and placed on mechanical ventilation. Hospital records confirmed that over 3.9 liters of fluid were drained from the resident's abdomen, and the event was attributed to excessive dialysate instillation at the facility. The lack of proper training, failure to follow physician orders, and inadequate communication and documentation directly led to this Immediate Jeopardy event.
Removal Plan
- The contract for dialysis was terminated with the facility.
- Facility Administrator and Director of Nursing reviewed all the residents at the time of the event and no other residents were receiving PD services at the time of the event and no other residents have received PD services since this event.
- Facility Administrator and Director of Nursing were in-serviced by dialysis company on manual fill PD.
- Both nurses involved in the event were suspended pending investigation and terminated.
- Facility policy for dialysis was reviewed by Regional Director of Operations and found to be in compliance.
- QA meeting was held with dialysis company and policies and procedures were reviewed.
- Administrator or designee will review PD patients weekly times 4 weeks.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Facility staff failed to follow dialysis care policies and the care plan for a resident with diabetes mellitus, chronic kidney disease, and an upper extremity hemodialysis fistula. Despite clear directions to avoid using the arm with the dialysis access for any treatment, including blood pressure measurement, staff repeatedly documented taking blood pressure on that arm over multiple months. The DON later confirmed that the resident’s blood pressure had been measured on the arm containing the dialysis access.
A resident with ESRD and diabetes who received hemodialysis three times weekly had a care plan requiring hemodialysis and administration of medications as ordered, but the facility failed to maintain complete dialysis communication documentation and to update an antihypertensive order per dialysis instructions. Dialysis documentation indicated the resident’s Amlodipine dose should be decreased to 5 mg daily, yet the medical record continued to reflect a 10 mg dose on specific days with hold parameters, and the change was never entered. Dialysis communication forms for two treatment dates were also missing, and both the DON and Regional Nurse Consultant confirmed the Amlodipine dose in the record was incorrect and that the dialysis communication sheets were not present.
A resident with sepsis, diabetes, and dependence on renal dialysis had physician orders for hemodialysis three times weekly and a care plan requiring monitoring of pre/post-dialysis weights and vital signs. Despite a facility dialysis management policy, nursing staff did not complete most pre-dialysis communication forms and had multiple dialysis communication sheets missing over several months. The RNAC and the NHA confirmed that required pre- and post-dialysis communication documentation between the facility and the dialysis center was not consistently completed or available.
A resident with ESRD on hemodialysis, hyperkalemia, and heart failure had physician orders and RD documentation for a renal diet with double protein portions at each meal and a 1000 mL/24-hour fluid restriction, with specific meal-by-meal fluid allocations. Observations showed the resident repeatedly received meal trays that exceeded the ordered fluid limits and did not provide double protein portions, including a lunch tray with 600 mL of fluids and non-renal-appropriate items such as potatoes and tomato-based ravioli, and a breakfast with only one egg instead of a double protein portion. The resident reported that staff frequently served foods inconsistent with his renal diet and were unaware of his fluid restriction, and a large cup of orange juice was observed at his bedside. Dietary and nursing staff interviews revealed lack of understanding of renal diet requirements, failure to use posted renal restriction lists, and absence of a system to ensure trays matched diet and fluid orders, while leadership acknowledged expectations that such orders be followed.
A resident with CKD stage five requiring peritoneal dialysis (PD) was admitted with pre-admission physician orders for three daily PD exchanges and monitoring for peritonitis (fever, abdominal pain, cloudy effluent), but these monitoring orders were not entered into the facility’s physician orders. The care plan referenced PD and general monitoring but did not specifically address peritonitis monitoring. Paper PD flowsheets showed incomplete and inconsistent documentation of exchanges and resident condition, including missing condition/comments for individual treatments and no record of one ordered PD exchange. The PD cycler flowsheet lacked effluent descriptions on multiple days. The PD nurse reported facility staff were expected to monitor effluent and symptoms, and the DON confirmed the absence of specific peritonitis monitoring orders, lack of an order for the PD cycler, and documentation gaps, despite a facility policy requiring ongoing assessment and monitoring for complications before, during, and after dialysis treatments.
A resident with HTN and ESRD who required scheduled hemodialysis did not have complete dialysis communication documentation as required by facility policy. The facility’s dialysis guidelines required use of a Hemodialysis Communication Form to share information such as vital signs, weights, and medications between the center and the dialysis provider. Review of the resident’s records showed that on one treatment date the post-dialysis weight was not recorded, and on another date blood pressure, pre- and post-dialysis weights, pulse, and medications given during hemodialysis were not documented. The DON confirmed that these sections of the forms should have been completed.
Improper Blood Pressure Measurement on Dialysis Access Arm
Penalty
Summary
Facility staff failed to provide appropriate dialysis-related care by not adhering to policy and the resident’s care plan regarding protection of a hemodialysis access site. The facility’s policy on hemodialysis external catheter evaluation and maintenance, last reviewed February 24, 2026, directed staff to avoid taking blood pressure from an arm with a dialysis access device. The resident, who had diabetes mellitus with chronic kidney disease and required ongoing hemodialysis, had a care plan initiated November 11, 2021 and last reviewed December 17, 2025 that instructed staff to monitor the left upper extremity fistula for bleeding and to avoid using that arm for any treatment to prevent complications related to dialysis access. Despite these directives, clinical record review showed that staff documented taking the resident’s blood pressure on the left arm 10 times in January 2026, 10 times in February 2026, 14 times in March 2026, and four times in April 2026. In an interview on April 17, 2026, the Director of Nursing confirmed that the documentation showed the resident’s blood pressure had been measured on the left arm containing the dialysis access. These findings were cited under 28 Pa. Code 211.10(d) Resident care policies and 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.
Failure to Implement Dialysis Communication and Updated Antihypertensive Orders
Penalty
Summary
The deficiency involves the facility’s failure to provide dialysis-related care and medication management according to professional standards for a resident with end stage renal disease and diabetes who required hemodialysis three times weekly. The resident’s care plan noted the need for hemodialysis and listed interventions such as administering medications as ordered and encouraging attendance at scheduled dialysis sessions. However, review of the medical record showed that dialysis communication forms were missing for two dialysis dates, and the existing dialysis communication form documented a change in the resident’s Amlodipine dosage from 10 mg to 5 mg daily that was not implemented in the medical record. The physician’s order in the chart continued to show Amlodipine 10 mg by mouth on specific days with hold parameters, and there was no documentation of the decreased 5 mg daily dose as communicated by dialysis. The DON and Regional Nurse Consultant acknowledged that the Amlodipine dose in the record was incorrect, that the dose should have been 5 mg every day, and that dialysis communication sheets for two dates were missing.
Failure to Maintain Required Dialysis Communication Documentation
Penalty
Summary
Facility staff failed to maintain ongoing communication with an outpatient dialysis center for a resident who was dependent on renal dialysis. The resident was admitted with diagnoses including sepsis, dependence on renal dialysis, and diabetes, and had a physician’s order to receive hemodialysis three days per week. The facility’s dialysis care plan included interventions to monitor pre- and post-dialysis weights, encourage attendance at scheduled dialysis appointments, and monitor vital signs with physician notification of significant abnormalities. The facility had a “Dialysis Management” policy stating it had designed and implemented processes to ensure the comfort, safety, and appropriate management of hemodialysis residents. Review of dialysis communication forms from January through April showed that 12 of 16 pre-dialysis communication forms were not completed by facility nursing staff on specified dialysis dates, and 16 additional dialysis communication sheets for other dialysis days were possibly missing and not available at the facility. The RN Assessment Coordinator confirmed that the facility failed to ensure the dialysis communication forms were completed pre- and post-treatment between the facility and the dialysis center and confirmed the missing sheets were not available. The Nursing Home Administrator also confirmed that the facility failed to ensure dialysis communication sheets were completed prior to dialysis treatment.
Plan Of Correction
Resident R1 receiving Dialysis will be reviewed with the Dialysis Nurse to ensure complete communication has occurred to provide for accurate Plan of Care for the residents. Resident receiving Dialysis will be reviewed with the Dialysis Nurse to determine that complete communication has occurred and that the accurate Plan of Care is in place for the resident. The Medical records staff will be educated to not upload any Dialysis communication that is not complete. Medical Records staff will communicate with the DON/Designee if this occurs. Nursing Staff will be educated on the need for accurate completion of the Dialysis Communication Form by the DON /Designee Audit of 10% of residents receiving Dialysis will have the Dialysis Communication form audited for completion and placement in the Resident Medical Record by the DON/Designee. These will be completed weekly times four and monthly times three. Results on these audits will be submitted to the QAPI committee for review and further recommendations.
Failure to Follow Renal Diet and Fluid Restriction Orders for Dialysis Resident
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders for a resident on hemodialysis who required a renal diet with double protein portions and a 1000 mL/24-hour fluid restriction. The resident had end stage renal disease, renal dialysis, hyperkalemia, and heart failure, and was care planned for increased nutrition and hydration risk related to these conditions, including a therapeutic renal diet and fluid restriction. The physician’s order and RD note specified a renal diet with double protein at every meal and a 1000 mL fluid restriction, with 600 mL to be provided by Dietary (240 mL at breakfast, 240 mL at lunch, 120 mL at dinner) and 400 mL by Nursing (200 mL on first shift and 200 mL on second shift). The care plan interventions included maintaining the fluid restriction as ordered and encouraging compliance with the prescribed diet. During a lunch observation, the resident’s tray ticket correctly listed a renal diet, a 1000 mL/day fluid restriction with a 240 mL limit at lunch, and double protein portions, but the actual tray contained items inconsistent with these orders. The tray included a small serving of beef ravioli with tomato sauce, potatoes and carrots, a dinner roll, strawberry ice cream, 8 ounces of water, and 8 ounces of ginger ale, totaling 600 mL of fluid at that meal alone, exceeding the 240 mL lunch allowance. Double portions of protein were not provided. The Medical Records Manager, who is a nurse aide assisting with meal delivery, did not recognize that the tray exceeded the fluid restriction or that the protein portion was not doubled, and she stated she was not sure what a renal diet consisted of. The resident reported that the facility did not follow his renal diet, that he was often served inappropriate foods such as potatoes and processed lunch meats, and that staff were not aware of his fluid restriction. An additional observation of the resident’s bedside table showed a large 12-ounce cup of orange juice that he stated had been provided with breakfast despite his fluid restriction. Interviews with dietary staff further demonstrated failures in implementing the ordered renal diet and fluid restriction. The Dietary Manager acknowledged that the small serving of ravioli did not meet the double protein requirement, that potatoes should not have been served due to the renal diet restriction, and that the tray ticket listing 8 ounces of water, 8 ounces of a beverage of choice, and 4 ounces of sherbet exceeded the resident’s 240 mL fluid limit at lunch. She also stated there was no system in place to ensure residents consistently received the correct diet or appropriate tray items. A dietary staff member who prepared the lunch tray stated she relied on the tray card and did not check the posted renal diet restriction list. A subsequent breakfast observation showed the resident received one fried egg and one slice of toast with 4 ounces of coffee, which the RD confirmed did not meet the ordered double protein portion, noting that a double portion would be 3–4 eggs. The DON stated she expected fluid and diet restrictions to be followed as ordered, with Dietary responsible for preparing trays per orders and Nursing responsible for reviewing tray tickets and being knowledgeable about special diets such as renal diets.
Failure to Implement PD Orders and Monitor Resident Receiving Peritoneal Dialysis
Penalty
Summary
The deficiency involves the facility’s failure to implement pre-admission physician orders for peritoneal dialysis (PD) and to provide ongoing monitoring for a resident with chronic kidney disease (CKD) stage five who required PD. Pre-admission orders dated 11/14/25 specified three daily PD exchanges at 6:00 A.M., 2:00 P.M., and 10:00 P.M., and directed staff to monitor for signs and symptoms of peritonitis, including fever, abdominal pain, and cloudy effluent. These monitoring orders were not entered into the facility’s physician orders. The resident’s care plan noted the need for PD and included general monitoring interventions (labs, signs of bleeding, bacteremia, septic shock, and significant vital sign changes), but did not specifically address the ordered monitoring for peritonitis. Review of PD documentation showed incomplete and inconsistent charting of treatments and resident condition. The paper peritoneal flowsheet had columns for time of PD and condition/comments, including instructions to call the nurse immediately for cloudy fluid, abdominal pain, or fever. However, the first entry on 11/15/26 at 2:00 P.M. only noted that the PD nurse completed the exchange, and the 10:00 P.M. entry that day had no condition/comment documentation. Subsequent days (11/16/25, 11/17/25, and 11/18/25) contained only one condition/comment entry per day rather than for each exchange, and there was no documentation that the 6:00 A.M. PD on 11/18/25 was completed. The PD cycler flowsheet starting 11/19/25 lacked any description of the effluent on multiple days. The PD nurse from the dialysis company stated facility staff were expected to monitor effluent for cloudiness and assess for abdominal pain and fever, and the DON confirmed there was no electronic physician order for peritonitis monitoring or for use of the PD cycler, that the paper charting did not allow for effluent description or symptom documentation for each treatment, and that PD was not documented at one ordered time. The facility’s dialysis policy required ongoing assessment and monitoring for complications before, during, and after treatments, which was not reflected in the documentation for this resident.
Incomplete Dialysis Communication Documentation for Resident Requiring Hemodialysis
Penalty
Summary
The facility failed to ensure that a resident requiring hemodialysis received services consistent with professional standards and its own dialysis communication policy. The facility’s Dialysis Guidelines policy required shared communication between the center and the dialysis facility using a Hemodialysis Communication Form, including timely documentation of medications, physician/treatment orders, laboratory values, vital signs, and weights. The clinical record for Resident 45, who had hypertension and end-stage renal disease and required renal dialysis on Monday, Wednesday, and as needed, showed incomplete Hemodialysis Communication Record Forms. On one date, the dialysis center did not document the resident’s post-dialysis weight, and on another date, the dialysis center did not document blood pressure, pre-dialysis weight, post-dialysis weight, medications given during hemodialysis, or pulse. In an interview, the Director of Nursing confirmed that the missing documentation on the communication forms should have been completed. These findings were cited under 28 Pa. Code 211.12 (d) (1) (2) (5) related to nursing services.
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