Failure to Ensure Timely Physician Notification and Emergency Preparedness for Dialysis Resident
Penalty
Summary
The facility failed to provide dialysis care and services consistent with professional standards of practice for a resident with end stage renal disease (ESRD) who was dependent on hemodialysis. The resident had medical orders for hemodialysis three times weekly, as well as instructions to keep the dialysis site dressing dry and intact, and to monitor for signs of infection, bleeding, drainage, and pain. Despite these orders, the facility did not follow up with the resident's attending physician when the resident missed a scheduled dialysis appointment. Review of nursing progress notes and interviews with the Director of Nursing (DON) confirmed that there was no physician follow-up documented after the missed dialysis session. Additionally, the facility failed to ensure that a dialysis emergency kit was readily available at the resident's bedside. During an observation and interview, it was noted that the dialysis kit, which is intended to provide immediate care in case of emergencies such as bleeding, was missing from the resident's room. Both the resident and the LVN confirmed that the kit had not been present for at least two weeks, and a search of the room and closet did not locate it. The DON confirmed that each dialysis resident should have a kit at the bedside and described its contents and purpose. Facility policies and procedures required that residents who require dialysis receive services consistent with professional standards and that nursing staff keep the physician informed of any changes in condition. The policies also specified that staff should be trained in emergency care for dialysis residents, including management of hemorrhage. The failure to follow up with the physician after a missed dialysis session and the absence of a dialysis kit at the bedside constituted deficiencies in the provision of safe and appropriate dialysis care.