Failure to Ensure Safe Dialysis Care and Monitoring for Resident with Multiple Access Sites
Penalty
Summary
Staff failed to provide safe and appropriate dialysis care for a resident with end stage renal disease who had both a left arm arteriovenous (AV) fistula and a central venous catheter (Permcath) for hemodialysis. The facility did not ensure that staff knew the location or contents of the required emergency kit, as the kit was not clearly labeled, was inconsistently stored, and lacked essential items such as a clamp for the Permcath. During an observation, an LPN was unable to locate the emergency kit and was unsure how to manage bleeding from the Permcath, indicating a lack of preparedness for emergencies related to the resident's specialized treatment access. The facility also failed to obtain and implement physician's orders for critical monitoring tasks, including vital signs, weight monitoring, and evaluation of both access sites before and after dialysis treatments. There was no clear documentation or physician's order specifying the care and evaluation required for the two separate access sites, and the electronic records did not prompt staff to complete these tasks. Additionally, the facility did not maintain the specialized treatment communication book or document vital signs, weights, or access site evaluations as required by facility policy on days when the resident received dialysis. Facility policies reviewed did not address the care of a Permcath (central line) used for dialysis, nor did they provide guidance for emergency situations involving this type of access. The care plan for the resident included interventions for the Permcath, but these were not supported by physician's orders or clearance from the dialysis provider. The lack of clear policies, orders, and documentation led to gaps in care and monitoring for the resident receiving specialized dialysis treatment.