Failure to Assess Dialysis Access Site Every Shift
Penalty
Summary
The facility failed to ensure that dialysis care was provided in accordance with its own policies and procedures for a resident requiring hemodialysis. Specifically, the facility's policy required that the dialysis access site (AV shunt or graft) be assessed for patency by auscultating for a bruit and palpating for a thrill every shift, not just on dialysis days. However, medical record review revealed that there was no documentation of these assessments being performed every shift for the resident during the month of June and from July 1 through July 17. Interviews with both a Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) confirmed that the assessments were only being performed and documented on dialysis days, rather than every shift as required by policy. The resident in question had a left upper arm AV shunt and was receiving hemodialysis three times a week per physician's orders. Despite this, the facility staff did not consistently assess the dialysis access site every shift, as evidenced by the lack of documentation in the medical record. The DON acknowledged that the facility's policy was not followed and verified the absence of required documentation for the specified periods.
Plan Of Correction
4. Facility plans to monitor effectiveness of the corrective actions and sustain compliance; Integrate QA Process: The DO will monitor the effectiveness of the process and report to the Administrator. Any findings will be presented to the Monthly QA&A meeting. The Plan of Correction was presented at the Quality Assurance (QA&A) committee meeting on 08/14/2025. Ongoing findings from audits will be reported to the QAPI/QAA monthly meetings for at least three months. Corrective action completion date: 8/23/2025