Failure to Consistently Document Dialysis Access Site Assessments
Penalty
Summary
The facility failed to assess and document the presence of a bruit and thrill at the dialysis access site as part of routine monitoring for a resident with End-Stage Renal Disease (ESRD) who required hemodialysis. According to the facility's contract with the off-site dialysis provider and the resident's active orders, auscultation and palpation of the shunt site for bruit and thrill were to be performed every shift. However, review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed that this order was not listed, and documentation of the assessment was only found on the dialysis communication forms for select dates. During staff interviews, the DON confirmed that the order for shunt site assessment was not included on the MAR/TAR and that documentation was incomplete, limited to the dialysis communication forms. The resident involved had a diagnosis of ESRD and moderate cognitive impairment, as indicated by a BIMS score of 12. The lack of consistent documentation and omission from the MAR/TAR led to a failure in ensuring routine monitoring of the dialysis access site as ordered.