Failure to Care Plan Dialysis for Resident with End Stage Renal Disease
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with end stage renal disease who was receiving dialysis three times a week at an external dialysis center. Despite the resident's medical history, which included diagnoses such as end stage renal disease, depression, dementia, muscle wasting, vitamin D deficiency, type 2 diabetes, and hypertension, the care plan did not address the dialysis treatment as required. The resident's annual MDS assessment indicated the need for dialysis, but this was not reflected in the care plan dated after the assessment. Interviews with nursing staff revealed that while routine preparations and checks were performed before the resident was transported for dialysis, these actions were based on the nurse's experience rather than guidance from a documented care plan. The MDS nurse acknowledged that the dialysis treatment should have been included in the care plan and attributed the omission to unintentional negligence. The facility's policy requires that all active problems identified in the comprehensive assessment be incorporated into the care plan, but this was not followed in the case of the resident's dialysis treatment.