Failure to Provide and Document Dialysis Care as Ordered
Penalty
Summary
The facility failed to ensure that dialysis care was provided according to physician orders and professional standards for two residents. For one resident, the facility did not ensure that the resident received scheduled hemodialysis treatments at an outpatient dialysis center as ordered by the physician. Medical record reviews and staff interviews confirmed that the resident did not leave the facility for dialysis on multiple scheduled days, and the dialysis center administrator verified that the resident was not dialyzed during the relevant period. The facility's own investigation concluded that the resident missed scheduled dialysis sessions, and the reason for the missed appointments was not documented, though it was noted that transportation could not be arranged. For another resident, the facility failed to accurately assess and document the resident's dialysis access site as ordered by the physician. The resident, who had end-stage renal disease and a Perma-Cath in the left thigh, had physician orders and communication records incorrectly specifying the access device as a Port-A-Cath, which is a different type of vascular access typically implanted in the chest wall. The DON confirmed that the physician's order was incorrect and that the resident's actual access was a Perma-Cath. These failures resulted in the residents not being provided with appropriate care and treatment as ordered by their physicians. The facility's policies required nursing care for dialysis residents to be provided in accordance with physician orders, but this was not followed in these cases, as evidenced by the missed dialysis treatments and incorrect documentation of dialysis access.
Plan Of Correction
Identified deficiencies will be corrected immediately by designee. The results of these audits will be presented to the QAPI Committee on a quarterly basis for further monitoring and/or action planning as needed. Completion Date: 10/25/2025