Failure to Ensure Accurate Assessment and Monitoring of Dialysis Access Site
Penalty
Summary
The facility failed to provide appropriate dialysis care and services for a resident with end stage renal disease who required hemodialysis. The resident was admitted with a history of ESRD, hypertension, and a left leg amputation, and had a left femoral artery permcath as the current dialysis access site. However, the clinical admission form did not indicate that the resident underwent dialysis, and the admission progress note incorrectly documented the dialysis access site as a right upper arm AVF instead of the left femoral permcath. This resulted in inaccurate documentation of the resident's dialysis needs and access site. Further review revealed that the facility did not complete thorough pre and post dialysis assessments for the resident on multiple occasions. Specifically, assessment forms for several dialysis dates were incomplete and did not include required evaluations of the dialysis access site after treatment. Both the RN and DON confirmed that licensed staff were required to assess the dialysis access site before and after each dialysis session, but this was not done as required. The facility's own policy mandated daily assessment and documentation of the vascular access site, as well as completion of pre and post dialysis evaluations by a licensed nurse. Observations and interviews confirmed that the resident was aware of her dialysis schedule and access site, but facility documentation and assessments did not accurately reflect her current treatment or provide the necessary monitoring. The lack of accurate admission documentation and incomplete pre and post dialysis assessments led to a failure in ensuring safe and appropriate dialysis care for the resident.