Failure to Provide Timely Dialysis Access Site Care
Penalty
Summary
The facility failed to ensure proper care of a dialysis access site for a resident with end stage renal disease who required hemodialysis. The resident, who attended dialysis three times a week, returned to the facility with a dressing on her right upper arm dialysis access site. Observations revealed that the dressing remained soiled and was not removed within the recommended timeframe. The resident reported that licensed nurses did not remove the dressing after her return from dialysis. Interviews with licensed nurses indicated they were unaware of the requirement to remove the dialysis dressing four to six hours after treatment, as specified in the communication record from the dialysis center. The nurses also admitted to not reading the communication record for updates or new orders. The Director of Nursing confirmed that the dressing should have been removed within the specified timeframe to prevent complications. The facility's policy required adherence to standards for care of residents on renal dialysis and their vascular access sites.