Failure to Ensure Proper Dialysis Care and Documentation
Penalty
Summary
The facility failed to provide safe and appropriate dialysis care and services for two residents requiring such care. For one resident receiving hemodialysis three times a week, there were multiple deficiencies in following physician orders and facility protocols. Orders required documentation of pre- and post-dialysis vital signs and weights, as well as the return and scanning of Dialysis Communication Sheets into the electronic medical record. However, vital signs and weights were frequently not documented, with staff often citing the resident's condition or absence for dialysis as reasons. Additionally, many Dialysis Communication Sheets were missing or not scanned into the system, and those that were available often lacked required information such as pre- and post-dialysis weights and blood pressures. For another resident with end stage renal disease and a dialysis shunt, the clinical record lacked essential information, including the type and location of the shunt, a physician's order to monitor the shunt site for infection, and documentation of nursing staff monitoring the site. The care plan also did not include interventions or approaches related to shunt care, despite facility policy requiring shunt site inspection every shift for signs of infection. Staff interviews confirmed the absence of these critical elements in the resident's record, and the infection preventionist was unable to identify the shunt location or find relevant orders in the chart. These deficiencies were identified through record reviews and staff interviews, which revealed that the facility did not consistently follow its own policies or physician orders regarding dialysis care and monitoring. The lack of documentation and incomplete communication between the dialysis center and facility staff contributed to the failure to ensure proper care for residents undergoing dialysis.