Failure to Consistently Complete Post Dialysis Assessments
Penalty
Summary
The facility failed to ensure consistent completion of post dialysis assessments for a resident with End Stage Renal Disease (ESRD) who received dialysis treatments while residing in the facility. Clinical record review showed that although pre-dialysis assessments were completed, post-dialysis assessments were missing on several occasions, specifically on 5/28/25, 6/6/25, and 6/9/25. The resident's care plan identified the risk for complications related to dialysis, and the facility's policy required ongoing assessment and monitoring before and after dialysis treatments. Interviews with staff, including an LPN and the Director of Nursing (DON), confirmed that the expected process was to complete both pre and post dialysis assessments and document them in the electronic health record. However, review of the resident's electronic health record revealed that post dialysis assessments were not completed or documented for the specified dates, contrary to facility policy and professional standards of practice.