Failure to Coordinate Dialysis Fluid Restrictions
Penalty
Summary
The facility failed to ensure proper coordination of care between the facility and the contracted dialysis center for a resident with end stage renal disease (ESRD) who required hemodialysis. Despite physician orders specifying "No bedside water and one beverage per meal tray" per the dialysis clinic, the resident was repeatedly observed with a 20 oz. cup of water or ice at the bedside, which the resident could access and consume. Documentation from the dialysis center indicated ongoing concerns about excessive fluid intake, including notes that the resident was gaining more fluid than could be removed during dialysis, and specific requests to reduce fluid intake and monitor liquid foods and snacks. The care plan and Kardex did not reflect the fluid restriction order, and interventions included encouraging fluid intake, which conflicted with the dialysis center's instructions. Interviews with facility staff, including an LPN/Unit Manager and the DON, confirmed that the fluid restriction was not communicated or implemented in the resident's care plan or Kardex, and that the necessary coordination with the dialysis center and facility registered dietitian had not occurred. The DON acknowledged the need for consultation between the facility RD and the hemodialysis center, which had not been done. No additional documentation or information was provided by facility leadership during the exit conference regarding this deficiency.
Plan Of Correction
F 698 Dialysis Fluid Restrictions ELEMENT #1 A fluid restriction order was entered into the electronic medical record for Resident #15. ELEMENT #2 Like residents that receive dialysis treatment; electronic medical records were reviewed to ensure that residents needing fluid restrictions had orders entered into the electronic medical record. Any resident identified to need fluid restrictions had orders entered into the electronic medical record. ELEMENT #3 The policy, Fluid Restrictions was reviewed and deemed appropriate. The policy, Fluid Restrictions remains in place. Registered Nurses, Licensed Practical Nurses and Registered Dietician were re-educated on the policy, Fluid Restrictions, with emphasis on residents receiving dialysis treatment and fluid restrictions. ELEMENT #4 The Director of Nursing and/or designee will conduct random audits of 5 residents receiving Dialysis treatments to ensure substantial compliance with fluid restrictions if ordered. Audits will be conducted weekly for four weeks then monthly for two months. Any concerns will be immediately addressed. The results of the audits will be reviewed by the QAPI committee monthly for 3 months for further recommendations. Any area of non-compliance will be addressed. The Administrator is responsible for sustained compliance. Date of Compliance: 7/8/2025