Failure to Monitor AV Fistula for Dialysis Resident
Penalty
Summary
The facility failed to provide appropriate care and services for a resident with a newly placed arteriovenous (AV) fistula required for dialysis. The resident reported that nursing staff did not touch, palpate, or assess the fistula. Medical record review showed the AV fistula was placed on 4/10/25, but there were no physician's orders to check the bruit and thrill until 5/7/25. Hospital discharge instructions specified that the fistula site should be checked daily to ensure the thrill remained the same. Documentation revealed that the thrill was only assessed by nursing staff on three occasions: 4/12/25, 4/13/25, and 4/20/25. The DON confirmed that there were no orders to monitor the bruit and thrill prior to 5/7/25, despite the need for ongoing assessment since the fistula was placed.