Failure to Complete Pre and Post Dialysis Monitoring
Penalty
Summary
The facility failed to ensure that residents receiving dialysis had appropriate pre and post monitoring as required by facility policy. For two of three sampled residents with end stage renal disease, documentation showed that pre and post dialysis monitoring forms were either missing or incomplete for multiple dialysis sessions. One resident had only one completed pre and post monitoring form for the entire month reviewed, despite having regular dialysis appointments scheduled three times per week. The resident also reported that staff did not assess them before or after dialysis sessions. The Director of Nursing (DON) confirmed the lack of completed forms and stated that the process involved nurses filling out pre-dialysis forms, which were then sent with the resident to the dialysis center, and post-dialysis assessments were to be completed upon the resident's return. For another resident, several post-dialysis monitoring forms were missing for multiple dates in the same month. The DON acknowledged that the post-dialysis forms were not completed for these dates. A licensed practical nurse described the monitoring process as including vital signs, weights, and assessment of the dialysis site, but the required documentation was not present in the records reviewed. The facility's policy required monitoring before and after dialysis to ensure residents' conditions were stable, but this was not consistently documented or performed as required.