Failure to Ensure Safe Dialysis Care and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to provide safe and appropriate dialysis care for residents requiring such services by not ensuring the use of Enhanced Barrier Precautions (EBP) during direct care, lacking proper physician orders for dialysis, and documenting inaccurate interventions in care plans. For one resident with chronic kidney disease and a central venous catheter (CVC) for dialysis access, staff did not post EBP signage or use gloves during dressing observation, and the care plan inaccurately documented monitoring for bruit and thrill, which are not applicable to CVCs. The unit manager confirmed that EBP should have been implemented but was not. Another resident with a history of end-stage renal disease had no physician order for dialysis in the electronic medical record, and the care plan included interventions for peritoneal dialysis (PD) despite the PD catheter having been removed prior to admission. Staff continued to document and apply gentamicin ointment to a nonexistent PD site, and the care plan lacked focus and interventions for hemodialysis. Both the DON and Infection Preventionist confirmed the inaccuracies in documentation and the failure to implement EBP for residents with dialysis access devices.