Failure to Assess and Document Dialysis Access Site Post-Treatment
Penalty
Summary
Facility staff failed to provide required assessment and monitoring for a resident who was dependent on hemodialysis. The resident, admitted with chronic kidney disease, dependence on renal dialysis, anemia in chronic kidney disease, and sepsis, had physician orders for dialysis three times weekly at an outside facility. The resident's care plan specified that staff should monitor, document, and report any signs or symptoms of infection or complications at the dialysis access site, including redness, swelling, warmth, drainage, bleeding, or hemorrhage. However, on two separate occasions following the resident's return from dialysis, there was no documented evidence that staff assessed the dialysis access site or the resident's general condition, as required by both the care plan and facility policy. Review of the Hemodialysis Communication Observation/Assessment forms for the relevant dates showed that sections for access site assessment, general condition, and pain level were left blank. The DON confirmed that staff were expected to assess and document the resident's status and access site immediately upon return from dialysis, but this was not done. Facility policy also required such assessments to be completed and documented. The lack of assessment and documentation was confirmed through record review and staff interview.