Inaccurate Dialysis Care Planning and Assessment for Resident with Vascular Catheter
Penalty
Summary
The facility failed to provide appropriate dialysis care for a resident with a vascular dialysis catheter in the right upper chest. The resident's care plan and medical records included interventions and assessments that were not applicable to the type of dialysis access present. Specifically, the care plan and post-dialysis documentation referenced monitoring for bruit and thrill, which are relevant for arteriovenous fistulas or shunts, not for vascular catheters. Additionally, interventions such as not drawing blood or taking blood pressure on the arm with a graft, and checking the fistula daily, were included despite the resident not having these types of access. Interviews with nursing staff, the MDS Coordinator, and the DON confirmed that the care plan and documentation contained inaccurate and inapplicable interventions for the resident's actual dialysis access. The errors were attributed to the use of a care plan library in the electronic health record, where inappropriate interventions may have been selected. The resident's records and care plan were not accurately individualized to reflect the specific type of dialysis access, leading to the potential for inappropriate care.