Failure to Provide Immediate Post-Dialysis Assessment and Documentation
Penalty
Summary
A deficiency was identified in the care of a resident with end stage renal disease, sepsis, and heart failure who required dialysis services. Upon review of the resident's medical record and interviews with the resident, nursing staff, and the Director of Nursing (DON), it was found that the facility did not provide immediate monitoring and documentation of the resident's vital signs or assessment of the dialysis fistula upon the resident's return from the dialysis treatment center. The resident reported that after returning from dialysis, a Certified Nursing Assistant (CNA) assisted him to his room, but no vital signs were taken and a nurse did not assess his dialysis fistula at that time. Further interviews revealed that the LPN relied on the Dialysis Progress Note from the dialysis center, which included vital signs, weights, and new orders, and stated that vital signs were taken in the morning before dialysis and again in the evening, with fistula assessments completed every morning. However, there was no documentation in the resident's medical record of immediate post-dialysis vital signs or fistula assessment. The DON confirmed that facility policy expected nurses to assess the resident and the dialysis fistula immediately upon return from dialysis and to document these findings, but this was not done in this case.