Failure to Assess and Document Pre-Dialysis Vital Signs Prior to Transport
Penalty
Summary
Facility staff failed to ensure that a resident requiring dialysis received care consistent with professional standards by not assessing and documenting the resident's current vital signs immediately prior to transport to the dialysis center. Record reviews showed that the resident's pre-dialysis vital signs were taken more than four hours before the resident left for dialysis on multiple occasions, despite facility policy and physician orders requiring that vital signs be taken within two hours of departure. Interviews with nursing staff and the Director of Nursing confirmed that vital signs are necessary to determine the resident's appropriateness for dialysis and to identify any potential complications before transport. The resident involved had a history of end-stage renal disease, dependence on renal dialysis, and kidney transplant failure, and required substantial assistance with activities of daily living. The care plan for this resident included monitoring vital signs and reporting abnormalities prior to dialysis. Facility policy and the care coordination agreement with the dialysis provider both required that current vital signs be communicated to the dialysis staff and that residents be assessed for medical stability before transport. Despite these requirements, the facility did not consistently follow these protocols, resulting in a failure to properly assess the resident's condition prior to dialysis treatments.