Failure to Document and Assess Post-Dialysis Care
Penalty
Summary
Facility nursing staff failed to ensure that a resident requiring dialysis received care consistent with professional standards of practice. Specifically, on multiple occasions, staff did not document or assess the resident’s vital signs, dialysis access site, or mental status after the resident returned from dialysis treatments. This lack of post-dialysis assessment and documentation was noted on three separate dates, despite the facility’s policy requiring such monitoring. The resident involved was an older adult with diagnoses including anemia, kidney disease, heart failure, and diabetes, and was cognitively intact. She received dialysis twice weekly. While pre-dialysis assessments and documentation were generally completed, the post-dialysis sections of the communication records were left incomplete by facility nurses, even though the dialysis center staff completed their own sections. There were also no progress notes reflecting pre- or post-dialysis assessments by nursing staff during the relevant period. Interviews with staff revealed a lack of awareness regarding the requirement to complete post-dialysis assessments and documentation. The DON was unaware that these sections were not being completed, and one LVN stated she did not know she was supposed to check the resident’s vitals upon return from dialysis. The facility’s policy clearly outlined the need for monitoring blood pressure, pulse, and access site after dialysis, but these steps were not consistently followed.