Failure to Update Care Plan for Dialysis-Dependent Resident
Penalty
Summary
The facility failed to revise the care plan for a resident with end-stage renal disease (ESRD) who was dependent on dialysis. The resident's care plan did not include essential information such as the dialysis provider, frequency of visits, days of the week, chair time, or the location and assessment frequency of the access site. Additionally, the electronic medical record lacked a physician order for dialysis and monitoring of the access site. The Minimum Data Set (MDS) assessments did not document that the resident had received dialysis during the observation periods. The care plan only included general monitoring instructions and did not specify individualized dialysis-related care needs. Interviews with facility staff confirmed that all nursing staff had access to the resident's care plan and Kardex, and that the director of nursing was responsible for ensuring the care plan was current and person-centered. Despite this, the care plan was not updated to reflect the resident's dialysis requirements. The facility's policy required comprehensive, person-centered care plans to be developed and revised by the interdisciplinary team after each assessment, but this was not followed for the resident in question.