Failure to Maintain Accurate Dialysis Records and Adhere to Care Standards
Penalty
Summary
The facility failed to maintain complete and accurate records related to dialysis communication and did not adhere to professional standards of practice for the care of a dialysis resident. Specifically, the care plan for a resident with end-stage renal disease (ESRD), chronic systolic congestive heart failure, and type II diabetes mellitus did not include the presence of an emergency kit at the bedside for potential bleeding or catheter dislodgement. Observation confirmed that no emergency equipment was present in the resident's room, despite this being a necessary precaution for dialysis care. Additionally, the facility did not ensure proper documentation and communication with the dialysis center. Review of consult sheets revealed incomplete and undated forms, and staff interviews confirmed that consult sheets were not consistently returned or filed in the clinical record. Blood pressure readings were documented as being taken from the resident's right arm on multiple occasions, despite physician orders for limb precautions prohibiting this. The DON acknowledged that staff were inaccurately documenting the site of blood pressure readings and confirmed the absence of required emergency equipment and incomplete consult documentation.