Inaccurate Documentation of Dialysis Care and Site Management
Penalty
Summary
The facility failed to ensure accurate documentation of dialysis care for two residents receiving dialysis treatments. For one resident with chronic kidney disease and a central venous catheter (CVC) for dialysis access, physician orders required monitoring for bruit and thrill, which are only present with an arteriovenous (AV) fistula. Nursing staff documented the presence of bruit and thrill in the medical administration record (MAR) despite knowing the resident had a CVC, not an AV fistula, and that such assessments were not applicable. Staff acknowledged the documentation was inaccurate but continued to record it due to limitations in the documentation system and lack of clarification with management. For another resident with end stage renal disease, physician orders required topical application of gentamicin to a peritoneal dialysis (PD) catheter site. However, the PD catheter had been removed prior to admission, and the site was healed. Nursing staff continued to document the application of gentamicin to the non-existent PD catheter site, despite being aware that the order was no longer appropriate. Facility leadership confirmed that documentation for both residents was inaccurate and did not reflect the actual care provided.