Failure to Update Care Plan for Dialysis Location
Penalty
Summary
The facility failed to maintain an accurate and up-to-date care plan for a resident with multiple complex medical conditions, including respiratory failure, type 2 diabetes, COPD, GERD, osteoarthritis, anemia, atherosclerotic heart disease, insomnia, schizophrenia, hypercholesterolemia, overactive bladder, borderline personality disorder, hypothyroidism, pyoderma, hypertension, anxiety, major depressive disorder, chronic kidney disease, kidney failure, and who was dependent on renal dialysis. The resident was cognitively intact and had a physician's order for hemodialysis every Monday, Wednesday, and Friday. The care plan, completed on 04/11/25, indicated that the resident received dialysis at a specific center in St. Clairsville and included interventions such as encouraging attendance at scheduled dialysis appointments, monitoring vital signs, and assessing the AV fistula site. However, interviews with staff at the St. Clairsville dialysis center revealed that the resident no longer received dialysis at their facility and had not done so for some time. Further interviews confirmed that the resident was actually receiving dialysis at a different center in Bridgeport. The resident also confirmed this information. Despite this change, the care plan had not been updated to reflect the new dialysis location, resulting in inaccurate documentation. The facility's policy requires the care plan to be individualized and based on the resident's comprehensive assessment, developed by an interdisciplinary team, but this was not followed in this instance.