Failure to Monitor and Document Dialysis Access Site
Penalty
Summary
The facility failed to provide appropriate monitoring and documentation for a resident with end-stage renal disease who required hemodialysis. Specifically, the nursing staff did not monitor the resident's arteriovenous (AV) fistula access site for complications at least daily, nor did they document the presence of thrill and bruit every day as required. The resident's care plan included instructions for monitoring and reporting signs of infection, insufficiency, bleeding, and peripheral edema, but there was no physician order in the electronic medical record for dialysis or for monitoring the access site. Additionally, the Minimum Data Set (MDS) assessments did not document that the resident received dialysis during the observation periods. Licensed nursing staff reported assessing the access site only before and after dialysis sessions and documenting these assessments on the dialysis communication sheet, but not on non-dialysis days. The facility's dialysis policy required that residents needing dialysis receive services consistent with professional standards and the care plan. Administrative staff confirmed that a physician's order for dialysis and daily monitoring of the access site was expected but not present in the resident's record.