Failure to Monitor and Document Dialysis Care and Daily Weights
Penalty
Summary
The facility failed to ensure that a resident requiring dialysis received appropriate monitoring and care as ordered by the physician. Specifically, the resident, who had multiple diagnoses including end stage renal disease, congestive heart failure, and chronic kidney disease, was not consistently monitored with pre and post dialysis assessments on scheduled dialysis days. There were multiple instances where these assessments were not completed or documented, as confirmed by record review and staff interviews. Additionally, daily weights, which were ordered by the physician due to the resident's medical conditions, were not consistently obtained or recorded over a period of more than two months. Interviews with facility staff, including a registered nurse, dietician, and the regional director of clinical operations, confirmed the lack of documentation and completion of both daily weights and dialysis assessments. The facility's own policy required pre and post dialysis assessments and daily weights per physician orders, but these were not followed for the resident in question. No explanations were provided for the missing documentation, and the deficiency was acknowledged by facility leadership during the survey.