Failure to Ensure Complete Dialysis Documentation and Adherence to Physician Orders
Penalty
Summary
The facility failed to provide safe and appropriate dialysis care for two residents requiring such services, as evidenced by incomplete and inaccurate documentation and failure to follow physician orders. For one resident, the Hemodialysis Communication Records were missing critical information such as documentation of the dialysis access site, swelling, drainage, pain, and whether there were new orders from the dialysis center. The records also showed inconsistencies regarding the type of access site being used, and there was a lack of documentation for required assessments like bruit and thrill. These omissions were verified by both nursing staff and the Assistant Director of Nursing (ADON), who confirmed that the records should have been completed accurately to ensure proper assessment and monitoring of the resident's condition before and after dialysis treatments. Another resident's care was similarly deficient, with Hemodialysis Communication Records missing documentation of post-dialysis assessments, including thrill, site type, swelling, drainage, pain, and post-hemodialysis complications. Additionally, the facility failed to accurately document and monitor the resident's fluid restriction as ordered by the physician. Instead of recording the actual fluid intake, staff marked the medication administration record (MAR) with an "X" each shift, and there was no documentation of fluid intake during meals by certified nursing assistants (CNAs). The ADON and nursing staff acknowledged that the fluid restriction was documented incorrectly and that there was no record of total fluid intake per meal. Furthermore, the facility did not ensure that blood pressure medications were administered to the resident after dialysis as per physician orders. On multiple occasions, the MAR indicated the resident was away for dialysis, but there was no documentation that the medications were given upon the resident's return, despite orders allowing for post-dialysis administration. The ADON confirmed the absence of documentation for these medications on the relevant dates. These failures were acknowledged by facility leadership during interviews and had the potential to prevent the identification of negative outcomes for residents receiving dialysis.