Inaccurate Documentation of Dialysis Access Site Assessments
Penalty
Summary
The facility failed to ensure that the medical record for a resident receiving dialysis was complete and accurate, specifically regarding documentation of dialysis access site assessments. The resident was admitted with diagnoses including dependence on renal dialysis and end stage renal disease, and had a permacath in the right upper chest for dialysis access. Facility policy required accurate recordkeeping, and physician orders directed staff to assess the dialysis access site for thrill, bruit, and bleeding every shift. However, review of the Medication Administration Record (MAR) showed that LPNs documented assessments of a 'shunt site' for thrill and bruit, even though the resident did not have a shunt but rather a permacath. Interviews with the LPNs revealed that they were aware the resident's dialysis access was a permacath and that they assessed the site for signs of bleeding and infection, but they failed to accurately document these assessments in the MAR, instead recording assessments for a shunt site. The Director of Nursing confirmed that the documentation did not accurately reflect the assessments performed on the resident's actual dialysis access site during the specified period.