Care Plan Lacked Dialysis Details for Resident with ESRD
Penalty
Summary
The facility failed to ensure that a resident's comprehensive care plan was revised to include essential information regarding his dialysis treatment. The resident, who had end-stage renal disease and was dependent on renal dialysis, had a care plan that documented his diagnosis, the presence of a shunt in his left arm, and instructions for monitoring the access site and avoiding blood pressure measurements in the affected arm. However, the care plan did not include the location and contact information for the dialysis center or specify the days on which the resident received dialysis. Additionally, the electronic medical record lacked a physician's order for dialysis, although a scanned communication form documented pre- and post-dialysis vital signs and related information. Interviews with staff revealed that information about the resident's dialysis schedule was typically communicated verbally rather than being documented in the care plan. A CNA stated that nurses would inform staff about which residents had dialysis, but was not aware of specific care plan details. A licensed nurse confirmed that the care plan should include dialysis information, and an administrative nurse acknowledged that the omission of dialysis days in the care plan was an oversight following the resident's return from the hospital. The facility's policy required that changes in a resident's condition be reflected in the care plan, but this was not followed in this case.