Failure to Document and Complete Post-Dialysis Assessments
Penalty
Summary
The facility failed to ensure that post-dialysis assessment and monitoring were completed and documented for a resident with end stage renal disease who was dependent on renal dialysis. Review of the resident's records showed there were no current physician's orders for monitoring and assessment upon return from dialysis, and no documentation of post-dialysis assessments, including vital signs, weight, and monitoring of the dialysis access site, after a certain date. Interviews with nursing staff confirmed that the expected practice was to obtain post-dialysis weight, vital signs, assess the dialysis access site, and document findings in a progress note and on the hemodialysis communication record form. However, these assessments and documentation were not completed as required. Further review of medication and treatment administration records revealed that orders for post-dialysis monitoring, including weight, vital signs, and assessment of the AV shunt site, had been discontinued and not reinstated, resulting in a lack of documentation for these parameters over a period of several months. The Director of Nursing acknowledged that the orders had been discontinued and that there was no evidence to show that post-dialysis assessments were completed during this time. This failure resulted in the potential for the resident to not achieve his highest practicable physical, mental, and psychosocial well-being.