Failure to Communicate Updated Dialysis Orders and Assess Post-Dialysis Complications
Penalty
Summary
A deficiency occurred when the facility failed to communicate a resident's updated dialysis access order to the dialysis team and did not adequately assess for post-dialysis complications. The resident, who had a history of severe bleeding complications from his right arm AV fistula, was discharged from the hospital with instructions to use a newly placed permcath for dialysis instead of the AV fistula. Upon admission, the facility did not update the dialysis team with these new orders, and the dialysis Communication Report sheet did not reflect the change or the recent complications. As a result, the dialysis nurse used the resident's AV fistula for treatment, unaware of the updated order to use the permcath. After the treatment, the resident developed severe right arm swelling and pain. The family member notified the nurse on duty, who observed the swelling and contacted the nephrologist. The resident was subsequently transferred to the hospital, where he was diagnosed with an acute cephalic vein thrombosis in the right arm. Record review revealed that the facility's admission and care planning documentation did not include the new permcath access site or the updated dialysis orders. The dialysis nurse did not have access to the hospital discharge documents uploaded into the facility's EMR, and the baseline care plan and order summary did not reflect the required use of the permcath. The facility's policies and service contract required timely and accurate communication of changes in dialysis orders, which was not followed in this case.