Failure to Document Post-Dialysis Weight for Dialysis Resident
Penalty
Summary
Facility staff failed to ensure that a resident receiving dialysis had their post-dialysis weight documented on two separate occasions. The resident, who had end stage renal disease, an arteriovenous fistula, and was dependent on renal dialysis, had a care plan that required monitoring of their vascular access and documentation of their condition before and after dialysis. However, reviews of the resident's Pre-Dialysis Evaluations showed that the post-dialysis weight was left blank on two dates. Interviews with staff revealed that weights were typically obtained from the dialysis center's report and not taken at the facility. The Director of Nursing acknowledged that the post-dialysis weight should have been documented and that staff should have re-weighed the resident upon return if the dialysis weight was not available. The facility's policy required completion of pre- and post-dialysis evaluations and maintenance of all dialysis-related documentation in the resident's medical record, but this was not followed in these instances.