Failure to Complete Post-Dialysis Assessments for Resident Receiving Dialysis
Penalty
Summary
The facility failed to provide dialysis services consistent with professional standards by not completing post-dialysis assessments for a resident who required such care. Review of the electronic health records (EHR) for a resident with end-stage renal disease and dependence on renal dialysis revealed multiple instances over a 60-day period where post-dialysis assessments were not documented, despite physician orders requiring complete pre- and post-dialysis vital signs, weight, and evaluation. The resident was cognitively intact and attended dialysis three times weekly as scheduled. Interviews with nursing staff, including LPNs, an RN, and the Director of Nursing (DON), confirmed that pre- and post-dialysis assessments were expected to be completed and documented on each dialysis day. The DON acknowledged that the identified dates lacked the required post-dialysis assessments and stated that her expectation was for these assessments to be completed and charted in the appropriate sections of the EHR. Facility policy also required staff to be educated and trained on the specific assessment data to be gathered for residents receiving dialysis.