Failure to Ensure Safe and Documented Dialysis Care
Penalty
Summary
The facility failed to provide safe and appropriate dialysis care for two residents requiring such services, as evidenced by incomplete documentation and lack of physician orders. For one resident with end-stage renal disease, there was no nursing documentation of post-dialysis vital signs monitoring, and dialysis communication forms for multiple dates were either incomplete or missing. Interviews with nursing staff confirmed that while vital signs were reportedly checked, there was no record of this in the resident's file or on the required forms. The resident's care plan and physician orders specified the need for monitoring and documentation, but these were not followed. For the second resident, also with end-stage renal disease, although communication forms regarding pre- and post-dialysis vital signs were present, there were no physician orders in place for the dialysis treatments or for obtaining and documenting vital signs before and after dialysis. Nursing staff interviews revealed that the admitting nurse, ADON, and DON were responsible for ensuring such orders were entered, but this was not done. The absence of orders was acknowledged by staff, who noted that this could lead to miscommunication and potential missed treatments. The facility's hemodialysis policy required nurses to monitor and document the status of the resident's access site after dialysis and to specify treatment orders, including frequency and duration. Despite this policy, the required documentation and orders were not consistently completed or maintained for the residents reviewed, resulting in a failure to meet professional standards of practice and the residents' care plans.