Inaccurate Dialysis Assessment Documentation for Residents with Permacath Catheters
Penalty
Summary
The facility failed to ensure accurate completion of pre- and post-dialysis assessments for two residents who were dependent on dialysis and had Permacath catheters in place. Both residents had complex medical histories, including type 2 diabetes, muscle weakness, and end-stage renal disease, and were dependent on staff for activities of daily living. Documentation in their medical records repeatedly indicated that a thrill and bruit were present at the dialysis access site, which is not possible with a Permacath catheter. Record reviews showed that for multiple dates, nursing staff checked off the presence of thrill and bruit on both pre- and post-dialysis assessment forms for these residents. During interviews, a registered nurse and the DON confirmed that this documentation was inaccurate, as Permacaths do not produce a thrill or bruit. The facility's policy required accurate documentation of dialysis care, including the use of the Pre/Post Dialysis form, and maintaining this information in the resident's medical record. The inaccurate charting of assessment findings was acknowledged by both the registered nurse and the DON, who stated that licensed nurses should not have documented the presence of thrill and bruit for residents with Permacaths. This failure to accurately assess and document the residents' dialysis access sites resulted in the maintenance of incorrect medical information in the residents' records.