Failure to Document and Complete Dialysis Access Site Dressing Checks
Penalty
Summary
The facility failed to ensure that residents requiring dialysis received care and services consistent with professional standards of practice. Specifically, for two residents with end stage renal disease who were dependent on renal dialysis, physician orders required that dialysis access site dressings be checked every shift, reinforced as needed, and the physician notified as necessary. However, review of the clinical records for both residents did not show evidence that these dressing checks were being completed as ordered. Interviews with the Director of Nursing revealed that a transcription error had occurred, resulting in the physician's orders not populating on the medication or treatment administration records for both residents. As a result, the facility could not provide documentation that the required dialysis access site dressing checks were performed. The DON confirmed that it was the facility's expectation for physician orders to be transcribed correctly and for the dressing checks to be completed and documented as ordered.