Failure to Follow Physician Orders and Document Dialysis Fistula Care
Penalty
Summary
The facility failed to follow physician orders and established policies regarding the care and monitoring of a dialysis fistula for a resident with end-stage renal disease who was dependent on hemodialysis. Specifically, staff did not consistently document daily monitoring of the fistula for thrill as ordered by the physician and outlined in the care plan. Documentation showed that the required assessment was only recorded on five occasions over a 33-day period, leaving 28 days without evidence of compliance. Additionally, the Medication Administration Record and Treatment Administration Record for the relevant months did not contain documentation of the required monitoring. The facility also failed to maintain and provide records of communication between the facility and the dialysis center, despite staff stating that a cover sheet with vital signs and other information was sent with the resident. Interviews with staff revealed a lack of awareness and adherence to the care plan requirements, with one LPN stating that they did not check the thrill as required. The Director of Nursing confirmed that the care plan should have been updated to reflect current physician orders and was unable to provide documentation of communication with the dialysis center.