Failure to Accurately Assess and Document Dialysis Access Site
Penalty
Summary
The facility failed to ensure that a resident receiving hemodialysis was provided appropriate dialysis care and services in accordance with facility policy and physician orders. Specifically, staff did not properly assess the resident's right femoral dialysis access site on multiple occasions, as required. Documentation and assessments were inaccurate, with staff incorrectly recording findings such as bruits and thrills, which are not applicable to a femoral central venous catheter but rather to an arteriovenous fistula. Additionally, the assessment forms indicated the wrong access site location, listing a right thigh access instead of the correct right femoral site. The resident involved had a history of end stage renal disease and a right femoral central venous catheter for dialysis. The care plan and physician orders required regular monitoring of the access site for signs of infection or leakage, as well as pre- and post-dialysis assessments. However, record reviews and staff interviews confirmed that these assessments were not performed accurately or consistently, leading to incomplete and potentially misleading documentation regarding the resident's dialysis access care.
Plan Of Correction
Immediate Corrective Action for resident affected by this deficient practice. DON re-assessed the right femoral hemodialysis site and found the site intact and covered. 06/13/25 Plan/Process to Identify other Residents potentially affected by same deficient Practice and Corrective Action(s) to be taken. No other residents were affected by the same deficient practice. Facility Measures and Systemic Changes to ensure the deficient practice does not reoccur: 1. 1:1 in-serviced to 5 CN for proper placement of Hemo Dialysis catheter. On 05/24/25, 05/25/25, 05/27/25, 05/29/25, 05/31/25, 06/03/25. 2. Medical Records to Audit this form daily and any deficient practices will be brought to DON to adhere to standards of practice. 3. Hemo dialysis Nursing pre and post communication record will also accompany new form "Dialysis Alert" to double down on precise location and description of access to receive proper care. 4. All licensed nurses were in-serviced on 6/13/2025 on accurate dialysis site assessment pre and post hemodialysis. Facility Plan to Monitor Corrective action(s); and Sustain Compliance: Beginning 7/01/25, DON or designee will review Performance and report to Administrator and report to QAPI monthly meetings for compliance. Monthly QA discussion will occur for 3 months.