Failure to Immediately Assess Dialysis Access Site Post-Treatment
Penalty
Summary
The facility failed to ensure that a resident who was dependent on hemodialysis received comprehensive assessments of her dialysis access site immediately after returning from dialysis treatments. Review of the resident's medical record and dialysis communication forms over a period of several months showed no evidence of immediate monitoring or documentation of the access site for bleeding or other complications upon return from the dialysis center. Although physician orders required completion of dialysis assessment forms before and after dialysis, as well as shunt assessments every shift, there was no documentation that the access site was evaluated right after the resident's return to the facility. Interviews with the Director of Nursing and Clinical Service Manager confirmed that while nurses were checking the resident's shunt during the shift, there was no evidence of an immediate post-dialysis assessment as required. The facility's policy stated that the Dialysis Communication Form should be completed each time the resident had dialysis, but the form lacked documentation of the resident's status immediately after returning from treatment. The resident involved had multiple diagnoses, including end-stage renal disease, diabetes, and cardiac conditions, and required assistance with activities of daily living.