Failure to Follow Dialysis Care Policy and Documentation Requirements
Penalty
Summary
Facility staff failed to follow their own policy for managing residents receiving dialysis, resulting in multiple deficiencies. Specifically, staff did not consistently assess or document the condition of dialysis catheters or arteriovenous (AV) fistula sites every shift for two residents who were receiving dialysis. Documentation on the Medication/Treatment Administration Record (MAR/TAR) and dialysis communication forms was incomplete, with missing entries for pre- and post-dialysis weights and site assessments. There was also a lack of documentation in progress notes regarding post-dialysis vital signs and site assessments, and no evidence that residents refused these assessments. For one resident, there was no physician order for dialysis, despite the resident receiving dialysis services. The care plan for this resident included monitoring for complications related to end stage renal disease (ESRD) and dialysis, but interventions such as checking for bruit and thrill were not documented as completed. The other resident had a physician order to attend dialysis but lacked documentation of required assessments and communication with the dialysis center. Additionally, the facility did not have contracts in place with the dialysis companies providing services to the residents. Interviews with staff, including an LPN and the Director of Nursing (DON), confirmed that required documentation and assessments were not consistently performed or recorded, and that physician orders and care plans were not always complete or up to date for residents receiving dialysis.