Failure to Provide Safe and Appropriate Dialysis Care and Emergency Preparedness
Penalty
Summary
The facility failed to provide safe and appropriate dialysis care for multiple residents requiring such services. Specifically, the facility did not ensure that physician orders for pre- and post-dialysis weights were followed for one resident, as post-dialysis weights were not obtained on the prescribed days but instead were taken on Thursdays, contrary to the order for weights to be taken on each dialysis day. This was confirmed by both the RNA and RN, who acknowledged the discrepancy between the physician's order and the actual practice. Additionally, the facility did not maintain complete and accessible dialysis emergency kits at the bedside for several residents. Observations revealed that some residents who were receiving dialysis did not have an emergency dialysis kit at their bedside, while others had kits that were incomplete, lacking essential items such as clamp scissors needed to prevent bleeding. Staff interviews confirmed the absence or incompleteness of these kits and acknowledged that the kits should be present and fully stocked for all residents undergoing dialysis. Furthermore, the facility's licensed staff inappropriately documented the presence of bruit and thrill for a resident with a central venous catheter, despite this assessment being applicable only to peripheral access sites. This was verified by both the RN and DON, who stated that such documentation was not appropriate for central catheter sites. The combination of these failures demonstrates that the facility did not adhere to its own policies and procedures regarding dialysis care and monitoring, as well as physician orders for dialysis-related assessments and emergency preparedness.