Failure to Follow Dialysis Care Orders and Provide Meals During Dialysis
Penalty
Summary
The facility failed to follow physician orders regarding the care of a resident requiring hemodialysis, specifically in the removal of a pressure dressing from the resident's arterial venous fistula after dialysis treatments. Despite repeated written and verbal instructions from the dialysis nurse and a physician's order to remove the dressing at 9:00 PM on designated days, the dressing was not removed as directed. This resulted in swelling at the fistula site, which prevented the dialysis center from accessing the site and led to a missed dialysis treatment. Documentation and interviews confirmed that the facility had been notified multiple times about the importance of timely dressing removal, but the order was not consistently reflected in the medication administration record prior to the incident. The resident involved had a history of end-stage kidney disease, stroke, muscle weakness, and limited mobility, and was severely cognitively impaired. The care plan included specific interventions to monitor the dialysis access site and avoid complications. However, the failure to remove the dressing as ordered was attributed by facility leadership to possible ongoing bleeding, though there was no documentation or provider notification to support this. The dialysis nurse and physician assistant both confirmed that the extended presence of the pressure dressing caused swelling and prevented the scheduled dialysis session. Additionally, the facility did not provide a bagged meal or snack for the resident during dialysis appointments, despite the resident being scheduled for dialysis during meal times. Interviews with nursing, dietary, and transportation staff revealed a lack of awareness and practice regarding the provision of meals or snacks for residents attending dialysis, and the dietary manager was unaware that such a provision was necessary. The resident typically ate breakfast before leaving for dialysis, but no arrangements were made for food during the treatment period.