Failure to Provide Pre/Post Dialysis Assessments and Communication
Penalty
Summary
The facility failed to provide safe and appropriate dialysis care for a resident with end stage renal disease who was dependent on renal dialysis. Specifically, the facility did not ensure ongoing assessment of the resident's condition or monitoring for complications before and after dialysis treatments, as required by both facility policy and professional standards of practice. Review of the resident's treatment administration record and nursing notes revealed that dialysis port assessments and vital signs were not completed prior to or after dialysis treatments. There was also no order entered for the frequency of vital sign monitoring, and the facility did not use a communication binder to facilitate information exchange with the dialysis unit. Interviews with facility staff, including a nurse tech, RN, and the DON, confirmed that pre/post dialysis assessments and communication binders were not consistently used for the resident. Staff indicated that communication with the dialysis unit was informal and not standardized, and that vital signs were only taken weekly or at the dialysis unit itself. The resident also reported that port site assessments and vital sign checks were not performed before or after dialysis, and that communication with the dialysis unit was sporadic. The DON acknowledged that these practices did not align with facility policy or standard of care.