Failure to Ensure Proper Monitoring for Dialysis Resident
Penalty
Summary
The facility failed to ensure proper monitoring for a resident receiving hemodialysis, as evidenced by inconsistent documentation and implementation of physician orders for pre- and post-dialysis vital signs. The resident, who had end stage renal disease, hemiplegia, and moderate cognitive impairment, was scheduled for dialysis multiple times per week. Review of the care plan and physician orders indicated that vital signs and weight were to be obtained before and after each dialysis session, with significant changes to be reported immediately. However, documentation revealed that on certain dates, pre- and post-dialysis vital signs were either not recorded or were recorded on days when dialysis was not performed. Interviews with staff, including an LPN and the DON, confirmed that there were ongoing issues with transportation for the resident, leading to changes in dialysis scheduling and confusion regarding the correct days for monitoring and documentation. The DON acknowledged that the correct orders were not updated in the system, resulting in staff performing and documenting vital signs on incorrect days. The facility's policy required accurate implementation of physician orders, but this was not consistently followed, leading to lapses in monitoring for the resident undergoing dialysis.