Failure to Follow Physician Orders for Peritoneal Dialysis
Penalty
Summary
The facility failed to follow physician's orders for peritoneal dialysis for a resident with multiple diagnoses, including end stage renal disease and dependence on renal dialysis. The orders required staff to take vital signs before and after dialysis, use the resident's morning weight and systolic blood pressure to determine dialysis dose, and to call the dialysis clinic for further instructions if the resident's weight exceeded 216 pounds. Additionally, specific instructions were provided for the use of different dialysis solution bags based on the resident's systolic blood pressure. However, the facility did not clarify conflicting orders regarding which bags to use when the systolic blood pressure was low, and staff did not consistently follow the orders as written. Review of dialysis treatment logs revealed multiple instances where the prescribed protocol was not followed. On several occasions, when the resident's systolic blood pressure was below the specified threshold, the dialysis solution bags used were based on weight rather than blood pressure, contrary to the physician's orders. There were also instances where the concentration of bags used was not documented, and when the resident's weight exceeded 216 pounds, there was no evidence that staff contacted the dialysis clinic for further instructions. Interviews with staff and the DON confirmed that the orders were not always followed and that documentation of required communications with the dialysis clinic was lacking.