Failure to Ensure Ongoing Dialysis Communication and Fistula Monitoring
Penalty
Summary
The facility failed to ensure ongoing communication with the dialysis center and did not consistently monitor the fistula site for a resident who required hemodialysis. The resident, who had diagnoses including dementia, anxiety, end stage renal disease, dependence on renal dialysis, and type 2 diabetes mellitus with diabetic neuropathy, received dialysis three times weekly. Facility policy required daily monitoring of the fistula or graft for pulse, buzzing, or thrill, and regular checks for patency. However, the resident's care plan and Medication Administration Record did not reflect daily monitoring for bruit/thrill, and only eight dialysis communication entries were documented over an eight-month period. Staff interviews confirmed that monitoring for bruit/thrill was not included in the resident's MAR or TAR, and there was confusion among staff regarding what information was sent to and received from the dialysis center. The Director of Nursing and other staff indicated that the facility's policy and physician's orders should be followed, but the required aftercare instructions and consistent communication with the dialysis center were lacking. The dialysis center also reported not receiving the expected documentation from the facility, and there was no communication binder in place for the resident.