Failure to Provide Safe and Consistent Dialysis Care and Monitoring
Penalty
Summary
The facility failed to provide dialysis care and services consistent with professional standards for two residents requiring hemodialysis. Facility policy required the use of a communication notebook to share relevant information between the facility and the dialysis provider, as well as monitoring of the dialysis access site each shift. For one resident with end stage renal disease, there was no evidence that staff completed or obtained dialysis communication forms for multiple dialysis sessions over several weeks. Additionally, staff did not consistently monitor the resident's dialysis catheter site as ordered, with missing documentation on specific shifts, and failed to document post-dialysis weights on several required days. The resident also reported that staff did not always monitor her catheter site. For another resident with end stage renal disease and a physician's order for hemodialysis three times a week, there was no documented evidence that the access site was monitored each shift as required by facility policy. The Infection Control Nurse confirmed the lack of documentation for this monitoring. These findings indicate that the facility did not adhere to its own policies and physician orders regarding the monitoring and communication necessary for safe dialysis care.