Inaccurate Dialysis Documentation and Care Planning
Penalty
Summary
The facility failed to provide consistent, complete, and accurate assessments for a resident receiving hemodialysis, as evidenced by discrepancies in documentation and care planning. Specifically, the dialysis communication forms completed by licensed nurses repeatedly documented the presence of bruit and thrill, which are indicators associated with a fistula, despite the resident having a right femoral tunneled catheter line and not a fistula. Interviews with staff revealed confusion regarding the type and location of the resident's dialysis access site, with some staff incorrectly identifying it as a port or an upper chest central line, while the actual site was a right femoral tunneled catheter. The care plan also inaccurately described the access site, and staff relied on incorrect information from the communication board and provider orders. The resident, admitted with end stage renal disease and receiving regular hemodialysis, had their access site managed exclusively by the dialysis center, with facility staff only reinforcing the dressing. Despite this, the facility's documentation and care planning did not accurately reflect the resident's current access site or the appropriate assessments, leading to inconsistent communication between the facility and the dialysis center. These documentation errors and lack of accurate care planning were confirmed through interviews and record reviews, highlighting a failure to ensure safe and appropriate dialysis care and services for the resident.