Failure to Revise Care Plan After Dialysis Placed on Hold
Penalty
Summary
The facility failed to revise the comprehensive care plan for a resident following a significant change in their dialysis treatment. The resident, who had a right-sided tunneled dialysis catheter placed for treatment of end stage renal disease (ESRD), reported not having received dialysis for over two weeks and noted that their access dressing had not been changed appropriately. The resident stated that the original dressing had fallen off and was replaced with gauze by a nurse, but there was no ongoing order for dressing changes since dialysis had been placed on hold. Staff interviews confirmed that the last dialysis session occurred on May 29, 2025, and that only RNs are permitted to perform central venous catheter (CVC) dressing changes, with no current orders in place for this care. Review of the resident's care plan showed it still reflected ongoing dialysis treatments and did not indicate that dialysis had been placed on hold after the last treatment date. The care plan also did not address the need for updated orders or care instructions regarding the CVC dressing in the absence of regular dialysis visits. Facility policy requires that care plans be reviewed and revised by the interdisciplinary team after each assessment, including significant changes, but this was not done in this case.