Failure to Follow Post-Dialysis Assessment and Monitoring Policy
Penalty
Summary
The facility failed to follow its own policy for the care and monitoring of a resident receiving dialysis. According to the facility's policy, a registered nurse was required to assess the resident with a complete set of vital signs and check the dialysis access site for bleeding every 15 minutes for two hours upon the resident's return from dialysis. Review of the clinical record for a cognitively impaired resident with kidney failure who received dialysis revealed that, on multiple occasions across several months, there was no documented evidence that these assessments or vital sign checks were performed as required. The Director of Nursing confirmed the lack of documentation for the required post-dialysis assessments and monitoring on the specified dates.