Failure to Monitor Fluid Intake and Complete Post-Dialysis Assessments
Penalty
Summary
The facility failed to provide dialysis care and services according to professional standards for a resident with end stage renal disease who was dependent on hemodialysis. The resident had physician orders for a strict fluid restriction and scheduled dialysis treatments at an outpatient center. Despite these orders, the resident was observed with a filled water pitcher at the bedside, and staff confirmed that the pitcher was accessible, which was contrary to the requirement to monitor and control fluid intake for dialysis patients. Additionally, the facility did not complete or document post-dialysis assessments for the resident after returning from dialysis on multiple occasions. Review of records and interviews with nursing staff and the DON confirmed that these assessments were not performed, even though facility policy required a licensed nurse to evaluate residents after dialysis. The lack of monitoring fluid intake and failure to assess the resident post-dialysis constituted a deviation from professional standards and facility policy.