Failure to Perform Required Dialysis Fistula Assessments
Penalty
Summary
The facility failed to ensure that a resident requiring dialysis received care in accordance with professional standards of practice. Specifically, nursing staff did not consistently assess the resident's dialysis fistula for thrill and bruit every shift, as required by physician orders and facility policy. Observation revealed that a nurse placed a stethoscope over the fistula to listen for bruit but did not properly assess for thrill. Interviews with nursing staff confirmed that the required assessments were often not performed, with one nurse stating that she either forgot or was too busy, and believed that the checks were unnecessary since the resident's fistula was assessed at the dialysis center. The resident involved was an adult male with diagnoses including alcoholic cirrhosis of the liver with ascites, congestive heart failure, and end stage renal disease requiring dialysis. The resident had intact cognition and confirmed that his fistula was not being checked by facility nurses. Facility leadership acknowledged that the assessments should have been performed each shift and that the failure to do so was not in line with established orders and policy. The facility's policy required checking for thrill and bruit each shift and monitoring for bleeding upon return from dialysis.