Failure to Document and Assess Post-Dialysis Care for Resident with Permcath
Penalty
Summary
The facility failed to provide safe and appropriate dialysis care for a resident with chronic kidney disease, diabetes mellitus, and morbid obesity who was dependent on dialysis. There were no physician orders in place regarding post-dialysis care or monitoring of the resident's permcath site. Additionally, there was no documented evidence in the electronic health record or 24-hour nursing reports that the permcath site was assessed for complications such as bleeding or infection upon the resident's return from dialysis treatments, as required by facility policy and the resident's care plan. Observations confirmed that the resident's permcath was visible, with the dressing dry and intact, and the resident reported that staff did not assess or monitor the site after dialysis. Interviews with nursing staff and the Director of Nursing revealed a lack of clarity regarding post-dialysis care orders and confirmed that vital signs and site assessments should be performed and documented, but this was not being done. The physician interviewed also expected post-dialysis assessments and documentation, which were not present in the resident's records.