Failure to Document Pre/Post Dialysis Assessments and Access Site Monitoring
Penalty
Summary
Facility staff failed to follow their dialysis care policy by not consistently documenting pre- and post-dialysis assessments for a resident with end stage renal disease who required hemodialysis. The policy required monitoring and documentation of the dialysis access site for color, warmth, redness, tenderness, pain, edema, drainage, and bruit once per shift, as well as maintaining all dialysis-related documentation in the resident's medical record. Review of the resident's care plan showed it did not specify the location of the access site or require documentation of bruit and thrill once per shift. Physician orders were in place for pre-dialysis assessments to be completed and sent with the resident to dialysis, but documentation was missing on several dates. Record review revealed multiple instances where required documentation was incomplete or missing, including blank entries for pre- and post-dialysis assessments, and lack of documentation regarding the access site assessment. Interviews with the ADON and DON confirmed that pre- and post-dialysis assessments were expected to be completed and documented, including the location of the access site and assessment of bruit and thrill. However, the records did not consistently reflect these practices, resulting in a failure to adhere to the facility's dialysis care policy.