Failure to Coordinate Dialysis Care and Prevent Resident-to-Resident Altercations
Penalty
Summary
The facility failed to ensure that a resident with end-stage renal disease (ESRD) was free from neglect during the admission process. The resident was transferred from another nursing home and had been receiving dialysis five days per week prior to admission. Upon arrival, no dialysis services were set up or scheduled, and there was no alternate dialysis treatment provided while waiting for a new provider. The resident did not receive dialysis for 12 days, during which time she experienced symptoms including shortness of breath, sweating, weakness, jaundice, and critical laboratory values such as elevated potassium, BUN, and creatinine levels, ultimately requiring hospitalization. Documentation showed that the resident's care plan and physician orders did not include dialysis, and there was no evidence of physician notification or follow-up regarding the missed treatments. Additionally, the facility failed to prevent resident-to-resident altercations involving two residents with behavioral and psychiatric diagnoses. There were multiple documented incidents where one resident was verbally and physically aggressive toward another, including hitting and pulling hair. Staff and other residents witnessed these altercations, and skin assessments confirmed bruising. Despite these repeated behaviors, care plans and interventions did not prevent further incidents, and both residents continued to have conflicts. The deficiencies were identified through interviews, record reviews, and observations, revealing lapses in care coordination, communication, and supervision. The facility's policies on abuse and neglect were not effectively implemented, as evidenced by the lack of timely action to secure necessary dialysis treatments and to prevent ongoing resident-to-resident altercations. The events led to significant harm and risk for the residents involved.
Removal Plan
- The Administrator and Assistant Director of Nursing (ADON) were in-serviced by the VP of clinical services on neglect related to coordination of care by not setting up dialysis treatments.
- All department heads on abuse and neglect policy and procedure and no staff was allowed to work until they were in-serviced on abuse and neglect.
- A 24-hour report sheet was made up to ensure that there were no dialysis residents that missed/needed set up for treatment.
- A quality assurance tool was implemented: On-going audit of the 24-hour report will be completed to ensure that no resident missed dialysis or needed dialysis set up and a Root cause analysis was completed for neglect related to coordination of care for all new residents and dialysis treatment.