Failure to Address Dialysis Care Needs on Admission Baseline Care Plan
Penalty
Summary
The facility failed to address the immediate care needs of a resident with end-stage renal disease who was dependent on dialysis. Upon admission, the resident's baseline care plan did not include any documentation or instructions regarding dialysis care and services, despite the resident's medical record indicating a diagnosis of end-stage renal disease and a regular dialysis schedule. The electronic medical record also lacked orders related to dialysis care, and staff interviews confirmed that no pre- or post-dialysis assessments, vital signs, weights, or site assessments were performed by facility nurses. The resident reported that staff did not obtain vital signs, pre-dialysis weight, or assess the dialysis site prior to his departure for dialysis treatments. Further interviews with facility staff revealed a lack of awareness and education regarding the resident's dialysis care requirements. A certified nurse aide was only aware of a fluid restriction and not of other dialysis-related needs. A licensed nurse acknowledged that the facility missed necessary orders and assessments for dialysis care upon admission, and the administrative nurse confirmed that the baseline care plan should have included dialysis instructions. The facility's policy required baseline care plans to include instructions needed for effective and person-centered care, but this was not followed for the resident in question.