Failure to Complete Pre- and Post-Dialysis Assessments
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to complete required pre- and post-dialysis assessments for a resident with diagnoses of hypertension, renal insufficiency, and diabetes mellitus who received dialysis three times a week. The resident's care plan specified that nurses were to document and monitor complications, pre- and post-dialysis weights, and access sites, and to complete pre- and post-dialysis assessments on each dialysis day. Clinical record review revealed multiple instances where pre-dialysis assessments were not completed on specified dates, as well as numerous dates where post-dialysis assessments were missing. The Assistant Director of Nursing confirmed that these assessments were expected but not documented as required.