Incomplete Baseline Care Plan for Dialysis Access Site
Penalty
Summary
The facility failed to develop a complete baseline care plan for a resident admitted with end stage renal disease, hypertension, and an acquired absence of the left leg below the knee. Upon admission, the resident had a left femoral permcath in place for dialysis access, as well as arteriovenous fistulas in both upper arms. Physician orders required monitoring of the left femoral permcath site for signs of infection or complications during every shift. The resident's cognitive skills were intact, and they required partial to moderate assistance with daily activities. Despite these needs and orders, the baseline care plan created within 48 hours of admission did not include any information regarding the resident's left femoral dialysis access site. Both the registered nurse and the director of nursing confirmed that the baseline care plan was incomplete and did not address the dialysis access site, which was necessary for the resident's immediate care. Facility policy required that baseline care plans include all essential health information to ensure proper care upon admission, but this was not followed in this instance.