Failure to Monitor Dialysis Access Site per Policy and Care Plan
Penalty
Summary
A resident with end stage renal disease and dependence on renal dialysis was admitted to the facility in April 2023. The facility's policy required licensed nurses to check the dialysis access site for patency by auscultating for a bruit and palpating for a thrill before and after dialysis and every shift. The resident's care plan also included an intervention to monitor the dialysis access site for a positive bruit and thrill every shift and as needed. However, there was no evidence in the medical record of a physician's order to perform these assessments as required by the facility's policy and the resident's care plan. Additionally, documentation review showed that the last recorded assessment of the dialysis site for bruit and thrill occurred on 9/21/2024, with no subsequent assessments documented until the issue was identified by surveyors. Staff interviews confirmed the absence of an order to monitor the dialysis access site as per policy, and the order was only obtained after the surveyor brought the concern to the facility's attention. This failure resulted in the resident not receiving dialysis access site monitoring consistent with professional standards of practice and the comprehensive person-centered care plan.