Failure to Complete Pre and Post Dialysis Assessments
Penalty
Summary
The facility failed to consistently complete required pre and post dialysis assessments for a resident with end stage renal disease and diabetes, as directed by current physician orders. Review of the electronic health record and monthly Treatment Administration Records revealed multiple dates where no pre and post dialysis assessments were documented, including several specific days across April, May, July, and August. During interviews, the resident was unable to recall if staff obtained vital signs before dialysis, though believed blood pressures were taken upon return. The Administrator and DON acknowledged the lack of dialysis assessments on the identified dates. Additionally, the facility was unable to provide a policy outlining the procedure for completing pre and post dialysis assessments.