Failure to Document Discontinuation of Hemodialysis and Permcath Removal
Penalty
Summary
The facility failed to document a physician's order to discontinue hemodialysis treatment and to send a resident for permcath removal, as required for a resident with end stage renal disease. The resident, who was cognitively impaired and dependent on staff for daily care, had an existing order for hemodialysis three times weekly. On review, it was found that a Dialysis Visit Note indicated an order to discontinue hemodialysis and arrange for permcath removal, but this was not documented in the resident's clinical record. The registered nurse involved acknowledged receiving the information from the dialysis center and discussing it with the nurse practitioner, but did not document the conversation or obtain the necessary order from the primary provider. The delay in obtaining and documenting the order for permcath removal resulted in the resident being sent for the procedure at a later date. The facility's policy required care and treatment to be consistent with professional standards, physician orders, and the resident's care plan, but these standards were not met in this instance. The lack of documentation and delay in action had the potential to result in health complications, including the risk of infection at the permcath site.