Failure to Complete Post-Dialysis Assessments and Documentation
Penalty
Summary
The facility failed to ensure that post-dialysis assessments were completed and accurately documented for a resident who required dialysis services. According to the facility's policy, staff were required to immediately monitor and document the status of the resident's access site, including vital signs and assessment for complications such as bleeding, redness, or edema, upon the resident's return from dialysis. Record review showed that for multiple dates, the post-dialysis section of the Pre/Post Dialysis Communication Form was not completed, and there was no documentation of the required assessments. The Assistant Director of Nursing confirmed that staff did not complete the necessary documentation, which should have included vital signs and the condition of the access site. The resident involved had a history of Wegener's Granulomatosis with renal involvement and morbid obesity.