Missed Dialysis Appointment Due to Insufficient Staffing
Summary
A deficiency occurred when a resident who was dependent on dialysis did not receive a scheduled dialysis treatment due to insufficient staffing. The resident, who was alert, oriented, and dependent on staff for activities of daily living, required hemodialysis three times a week as ordered by her physician and documented in her care plan. On the date in question, there was no documentation in the resident's medical record or pre- and post-dialysis treatment forms indicating that dialysis was provided. Interviews with facility and dialysis staff confirmed that the resident missed her dialysis appointment because there were not enough staff available to get her out of bed and transport her to the in-house dialysis unit. The dialysis nurse reported that the CNA assigned to the resident was unable to assist due to a migraine, and no other staff were available to provide the necessary transport. Despite attempts by dialysis staff to coordinate with facility staff, the resident was not brought to her appointment, and the dialysis treatment was missed. Further review revealed discrepancies in documentation, as the Medication and Treatment Administration Record indicated the resident attended dialysis, but this was later confirmed to be inaccurate by the Director of Nursing and dialysis staff. The facility's agreement with the dialysis provider specified that the facility was solely responsible for transporting residents to and from dialysis at scheduled times, and missing or late arrivals could result in missed treatments. The deficiency was substantiated by interviews, record reviews, and facility policy.
Penalty
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A resident with CKD stage five requiring peritoneal dialysis (PD) was admitted with pre-admission physician orders for three daily PD exchanges and monitoring for peritonitis (fever, abdominal pain, cloudy effluent), but these monitoring orders were not entered into the facility’s physician orders. The care plan referenced PD and general monitoring but did not specifically address peritonitis monitoring. Paper PD flowsheets showed incomplete and inconsistent documentation of exchanges and resident condition, including missing condition/comments for individual treatments and no record of one ordered PD exchange. The PD cycler flowsheet lacked effluent descriptions on multiple days. The PD nurse reported facility staff were expected to monitor effluent and symptoms, and the DON confirmed the absence of specific peritonitis monitoring orders, lack of an order for the PD cycler, and documentation gaps, despite a facility policy requiring ongoing assessment and monitoring for complications before, during, and after dialysis treatments.
A resident with ESRD, diabetes, COPD, CHF, and dependence on renal dialysis received hemodialysis three times weekly at an off-site center, but the facility did not complete or document required pre- and post-dialysis assessments. The care plan and physician orders called for monitoring lung sounds, edema, AV fistula bruit and thrill, shunt site, and overall condition, yet the medical record contained no facility assessments around dialysis treatments. The only available pre-/post-treatment data (vital signs, weights, condition, and medications) came from the dialysis center’s communication forms. An LPN stated she filled out a form in a binder sent with the resident but could not produce the binder or a sample form, and the DON confirmed no facility-completed assessments could be located, despite a policy requiring assessment and monitoring for residents receiving dialysis.
The facility did not consistently complete or provide required information on dialysis handoff communication reports for multiple residents receiving dialysis, omitting vital signs, weights, code status, mental status, and other critical information. Nurse signatures were often missing, and there was a lack of documentation regarding access sites and catheter dressings after dialysis. Staff interviews confirmed that the expected processes for communication and assessment were not followed, and care plans lacked necessary interventions for monitoring dialysis-related complications.
The facility did not maintain ongoing communication with dialysis providers for two residents requiring hemodialysis. Staff interviews and record reviews showed that information was not consistently sent to or received from the dialysis center, and required communication sheets were not regularly used. This resulted in a lack of documentation and exchange of critical care information between the facility and the dialysis provider.
A resident with end stage renal disease and both a left arm fistula and a central venous catheter (CVC) for dialysis did not have documented assessments or monitoring of these access sites by facility staff, despite regular dialysis orders and facility policy requiring such oversight. Interviews and observations confirmed the presence of both access points, but the Director of Nursing acknowledged the lack of documentation.
A resident with end stage renal disease and cognitive impairment missed multiple scheduled dialysis appointments due to failures in transportation arrangements and communication among staff and the transportation provider. The resident was not transported as ordered, resulting in hospitalization for missed dialysis. Facility policy required safe transportation to dialysis, but this was not consistently followed.
Failure to Implement PD Orders and Monitor Resident Receiving Peritoneal Dialysis
Penalty
Summary
The deficiency involves the facility’s failure to implement pre-admission physician orders for peritoneal dialysis (PD) and to provide ongoing monitoring for a resident with chronic kidney disease (CKD) stage five who required PD. Pre-admission orders dated 11/14/25 specified three daily PD exchanges at 6:00 A.M., 2:00 P.M., and 10:00 P.M., and directed staff to monitor for signs and symptoms of peritonitis, including fever, abdominal pain, and cloudy effluent. These monitoring orders were not entered into the facility’s physician orders. The resident’s care plan noted the need for PD and included general monitoring interventions (labs, signs of bleeding, bacteremia, septic shock, and significant vital sign changes), but did not specifically address the ordered monitoring for peritonitis. Review of PD documentation showed incomplete and inconsistent charting of treatments and resident condition. The paper peritoneal flowsheet had columns for time of PD and condition/comments, including instructions to call the nurse immediately for cloudy fluid, abdominal pain, or fever. However, the first entry on 11/15/26 at 2:00 P.M. only noted that the PD nurse completed the exchange, and the 10:00 P.M. entry that day had no condition/comment documentation. Subsequent days (11/16/25, 11/17/25, and 11/18/25) contained only one condition/comment entry per day rather than for each exchange, and there was no documentation that the 6:00 A.M. PD on 11/18/25 was completed. The PD cycler flowsheet starting 11/19/25 lacked any description of the effluent on multiple days. The PD nurse from the dialysis company stated facility staff were expected to monitor effluent for cloudiness and assess for abdominal pain and fever, and the DON confirmed there was no electronic physician order for peritonitis monitoring or for use of the PD cycler, that the paper charting did not allow for effluent description or symptom documentation for each treatment, and that PD was not documented at one ordered time. The facility’s dialysis policy required ongoing assessment and monitoring for complications before, during, and after treatments, which was not reflected in the documentation for this resident.
Failure to Perform and Document Pre- and Post-Dialysis Assessments
Penalty
Summary
The facility failed to ensure a resident who required dialysis received ongoing assessments of condition before and after dialysis treatments, as required by facility policy and physician orders. The resident had been admitted with multiple diagnoses including end stage renal disease, diabetes mellitus, dependence on renal dialysis, morbid obesity, COPD, and CHF, and received dialysis three times per week at an off-site location. The care plan noted the resident frequently refused dialysis and included interventions such as monitoring lung sounds, edema, shunt site, bruit and thrill, and maintaining communication with the dialysis center. Physician orders included checking the left arm AV fistula for bruit and thrill every shift and documented the scheduled dialysis days and times. Medical record review revealed no evidence that the facility completed pre-treatment or post-treatment assessments related to the resident’s dialysis sessions. Although the dialysis center’s communication forms from several months documented pre- and post-treatment weights, vital signs, condition, and medications administered, these were completed by the dialysis center, not the facility. An LPN reported that the resident had a binder taken to dialysis and that she filled out a form with vital signs and any signs or symptoms of pain or sickness, but she could not produce the binder or a sample of the form. The DON confirmed she was unable to locate any pre- or post-dialysis assessments completed by facility staff and verified that the available communication forms were from the dialysis center, not the facility, despite the facility’s Dialysis Management policy requiring assessment and monitoring for complications.
Failure to Maintain Communication and Documentation for Dialysis Care
Penalty
Summary
The facility failed to maintain adequate communication and collaboration with the dialysis clinic regarding the care and services for multiple residents requiring dialysis. Specifically, the facility did not consistently complete or provide required information on the Dialysis Hand Off Communication Reports for several residents, including vital signs, weights, code status, mental status, vaccination status, allergies, diet and fluid restrictions, compliance with diet and fluids, new medications, medical problems, lab draws, and signs or symptoms of infection. Additionally, nurse signatures were frequently missing from both pre- and post-dialysis sections of the communication forms, and there was a lack of documentation regarding the condition of access sites and catheter dressings upon residents' return from dialysis. Several residents with complex medical histories, such as end stage renal disease, chronic respiratory failure, dependence on ventilators, and feeding tubes, were affected by these deficiencies. For example, one resident with severe cognitive impairment and multiple comorbidities had repeated omissions in the reporting of vital signs, infection status, and nurse signatures before and after dialysis sessions. Other residents, including those with moderate cognitive impairment or intact cognition, also experienced similar lapses in documentation and communication, with entire sections of the required forms left blank and no evidence of pre- or post-dialysis assessments being completed. Interviews with facility staff, including LPNs and the DON, confirmed that the expected process for completing and reviewing dialysis communication reports was not being followed. The facility's own policies and the dialysis coordination agreement required written communication of changes in resident condition and compliance with medical management, but these were not adhered to. Furthermore, care plans for residents receiving dialysis often lacked interventions related to monitoring for changes in mental status, infection, or fluid status, and there were no physician orders for pre- and post-dialysis assessments for the affected residents.
Failure to Ensure Ongoing Communication with Dialysis Providers
Penalty
Summary
The facility failed to ensure ongoing communication with dialysis providers for two residents who required hemodialysis. Both residents had diagnoses including end stage renal disease and were receiving dialysis three times a week. Review of their medical records and care plans indicated that staff were directed to encourage attendance at dialysis appointments, but there was no documentation of communication between the facility and the dialysis center. Staff interviews revealed that information was not consistently sent with residents to the dialysis center, and when residents returned, the facility typically did not receive or review information from the dialysis center, except occasionally for laboratory work. Nurses reported that communication sheets were not being used regularly, and the dialysis center confirmed they had not received information from the facility for several months. The Director of Nursing stated that nurses were responsible for completing and sending dialysis communication sheets with residents for every treatment, and that returned sheets should be uploaded to the electronic medical record and placed in the paper chart. However, this process was not being followed, as evidenced by the lack of documentation and staff statements. Facility policy required arrangements with the contracted dialysis provider to include how information would be exchanged, but this was not occurring, resulting in a deficiency related to the management and communication of dialysis care for residents.
Failure to Assess and Document Dialysis Access Sites
Penalty
Summary
Facility staff failed to assess, observe, and document the care of a resident's left arm fistula site and external central venous catheter (CVC) dialysis access site. The resident, who had diagnoses including end stage renal disease, dialysis dependence, diabetes, and heart disease, was admitted with both a CVC in the left upper chest and a fistula in the left arm. Despite physician orders for dialysis three times weekly and the presence of both access points, there was no documented evidence in the resident's orders, medication administration record, treatment administration record, progress notes, or care plan that staff assessed or monitored either the CVC or fistula. Interviews confirmed that the resident regularly attended dialysis and had both access sites in place for several months. Direct observation verified the presence of both the fistula and the CVC, with appropriate dressings in place. The Director of Nursing acknowledged that the medical record did not reflect any assessment or monitoring of the dialysis access sites. Facility policy required ongoing assessment and oversight of residents before, during, and after dialysis, including monitoring for complications and infection control, but this was not documented for the resident in question.
Failure to Ensure Timely Transportation for Dialysis Appointments
Penalty
Summary
A deficiency occurred when the facility failed to ensure a resident requiring dialysis was transported to scheduled dialysis appointments as ordered by the physician. The resident, who had end stage renal disease, type 2 diabetes, and vascular dementia, was dependent on staff for mobility and personal care, and required dialysis three times per week. Documentation revealed that the resident missed multiple dialysis appointments due to failures in transportation arrangements and communication among facility staff and the transportation provider. On at least two occasions, the resident missed dialysis appointments. On one occasion, the transportation company did not arrive, and on another, the transportation provider reported that the driver arrived on time but could not locate staff to bring the resident to the lobby, resulting in the resident not being transported. There was conflicting information from staff regarding whether the resident was waiting in the lobby, but no documentation supported that the resident was present and ready for pick-up. The facility's process for notifying and preparing residents for transportation was inconsistent, with some staff unaware of scheduled appointments and others not following established procedures for confirming transportation. As a result of missed dialysis, the resident experienced a decline in condition and required hospitalization for missed dialysis, where she received two sessions of dialysis. Interviews with staff and the resident's family member confirmed that the resident had missed dialysis appointments while at the facility. The facility's policy required arrangements for safe transportation to and from dialysis, but this was not consistently implemented, leading to the deficiency.
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