Failure to Provide Safe Dialysis Care and Maintain Required Documentation
Penalty
Summary
The facility failed to provide safe and appropriate dialysis care and services for a resident with end stage renal disease (ESRD) who was dependent on renal dialysis. Despite having a physician order specifying dialysis three times per week at an outside facility and a clear directive for dialysis precautions—specifically, no blood draws, injections, or blood pressure measurements from the resident's left arm—documentation showed that blood pressure was recorded as being taken from the left arm on nine occasions. The resident's care plan also included instructions to avoid the left arm for these procedures and to coordinate care with the dialysis center. Additionally, the facility did not maintain complete records of dialysis communication forms, which are used to facilitate the exchange of assessment data between the dialysis center and the nursing facility. Multiple dates were identified where the resident attended dialysis, but no corresponding communication forms were available in the clinical record. The Director of Nursing confirmed the absence of these forms and acknowledged that they should have been completed and available for review.