Missed Gabapentin Doses During Dialysis
Summary
The facility failed to provide safe, appropriate dialysis-related medication services for a resident with ESRD who was dependent on hemodialysis. The resident had diagnoses including end stage renal disease, dependence on renal dialysis, and a left below-knee amputation, and was cognitively intact with a BIMS score of 15. The resident had an implanted left upper chest wall port-a-cath for hemodialysis and was scheduled for dialysis on Monday, Wednesday, and Friday with a chair time of 10:50 AM. The resident also had an order for Gabapentin 100 mg by mouth three times daily for neuropathy. The medication administration record showed that the 1:00 PM dose repeatedly occurred while the resident was out of the facility at dialysis, and the dose was not administered on multiple dialysis days. In June 2025, 9 of 24 doses were coded as out of facility or other; in July 2025, 13 of 31 doses were coded as out of facility; in August 2025, 12 of 31 doses were coded as out of facility; and in September 2025, 7 of 15 doses were coded as out of facility or other. The corresponding progress notes showed the resident was at dialysis and did not receive the 1:00 PM Gabapentin dose on those dates. During interview, the LPN stated the resident was at dialysis on M/W/F and she was unable to administer the 1 PM dose, and she was not sure what else she should have done, adding that she maybe could have let her supervisor know. The UM/RN stated the nurse should have looked at the dialysis schedule, that the resident would not return for the 1 PM dose, and that the nurse should call the physician every time there was a missed dose and document that contact; she acknowledged there were no progress notes showing the physician was called when the dose was missed. The consultant pharmacist stated a resident on dialysis should not have medications scheduled when they are out of the facility for dialysis and expected the nurse to follow the chain of command to make the necessary change. The facility policies stated medications are to be administered safely and in accordance with prescriber orders, and medication omissions are considered medication errors.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Incomplete Dialysis Communication Documentation: The facility failed to fully complete the dialysis communication sheet for a resident receiving dialysis services. An LPN stated staff completed assessments and communication sheets before dialysis and upon return, while the DON said staff were expected to complete the sheets completely. Review showed multiple return-from-dialysis sections were left blank, and no earlier communication sheets were provided.
Failure to Document Post-Dialysis Assessment: A resident with ESRD who received hemodialysis twice weekly returned from treatment and reported staff rarely assessed her afterward or checked her chest port. The RN confirmed a pre- and post-dialysis assessment should have been completed and documented on the Dialysis Communication Form, but no post-dialysis assessment was found in the EMR and there was no evidence the resident refused care.
Incomplete Post-Dialysis Assessment Documentation: A resident with DM, COPD, and dependence on dialysis had repeated missing post-HD assessments on the dialysis communication sheet. The care plan and MD orders included dialysis attendance, AV fistula/graft monitoring, and pre-dialysis weights, but staff stated the resident was to be assessed after returning from dialysis and documented on the communication sheet; however, post-dialysis documentation was absent on many dialysis dates.
A resident with ESRD, DM2, and dependence on dialysis missed a scheduled hemodialysis treatment because transport was not arranged after a hospital return. The resident was observed waiting in the lobby for pickup, and staff later stated the dialysis center had not been updated about the hospitalization. The SSD and RT both acknowledged the facility was responsible for notifying the dialysis center and arranging transport, and the dialysis agreement and dialysis monitoring policy reflected that responsibility.
Failure to Monitor Fluid Restriction for a Resident Receiving Dialysis: A resident with ESRD, dependence on renal dialysis, and pleural effusion had a physician-ordered 1200 ml/day fluid restriction, but the MAR and record review showed no documentation of oral intake monitoring. The RNS stated she could not find intake monitoring documentation and noted the resident also lacked a care plan for the fluid restriction, despite facility P&P requiring intake/output documentation and a plan of care for residents on fluid restrictions.
A resident receiving PD was involved in a procedure where an RN did not perform hand hygiene before donning gloves, entered the room without closing the door, and then put on a mask from the resident’s bedside table while continuing the same procedure. The facility’s PD disconnecting procedure required the door to be closed, a mask to be applied, and hand hygiene to be performed before gloves were applied, and the RN had not received facility training related to the resident’s PD.
Incomplete Dialysis Communication Documentation
Penalty
Summary
The facility failed to complete the dialysis communication sheet for one resident who required dialysis services. The resident had a physician order dated 5/20/2026 for dialysis at a third-party dialysis provider on Tuesday, Thursday, and Saturday, with a 7:00 AM pickup time and 7:30 AM chair time, transported by wheelchair. Review of the resident’s dialysis communication forms showed that the section for facility completion upon return from dialysis was not completed on 8/8/2026, 8/6/2026, 8/4/2026, 8/1/2026, and 7/28/2026, and no other communication sheets were provided prior to 7/28/2026. Staff interviews indicated that an LPN completed assessments and communication sheets before dialysis and upon return, and the DON stated that staff were expected to complete the communication sheets completely and that progress notes would be on the communication sheet. The facility policy titled Clinical Dialysis Management stated that facility personnel will provide information useful or necessary for the resident’s care to the dialysis center as needed.
Failure to Document Post-Dialysis Assessment
Penalty
Summary
The facility failed to complete and document a post-hemodialysis assessment for a resident with end-stage renal disease who received dialysis twice weekly and had intact cognition with no refusal of care documented. The resident’s care plan noted that she returned from dialysis tired, often went straight to her room to nap, and required monitoring for increased fatigue and assistance with activities of daily living and mobility as needed. Her EMR also included orders related to her chest port dressing, including routine dressing changes and sterile care instructions. On the day in question, the resident returned from dialysis and stated that staff rarely assessed her when she came back from treatment and did not check her port. She exposed the chest port during the interview, and the dressing was dry and intact without bleeding or drainage. Review of the resident’s progress notes, evaluation notes, and EMR found no documentation of a post-dialysis assessment, and there was no evidence that she refused the assessment. The nurse on duty confirmed that a pre- and post-dialysis assessment should have been completed and documented on the Dialysis Communication Form, but she could not locate the form for that day and stated she did not recall seeing it when the resident returned.
Incomplete Post-Dialysis Assessment Documentation
Penalty
Summary
Safe, appropriate dialysis care/services were not provided for a resident who required hemodialysis. The resident had diagnoses of DM, COPD, dependence on dialysis, and dependence on supplemental oxygen, and the MDS documented a BIMS score of 15 with dialysis received during the observation period. The care plan included interventions for dialysis attendance, shunt monitoring, blood pressure precautions for the shunt arm, and daily weights, but the dialysis-related documentation was incomplete. The physician orders included dialysis on Monday, Wednesday, and Friday, readiness for dialysis by 10:30 AM, monitoring of the AV fistula/graft site upon return from dialysis, and weighing before dialysis for fluid management. Review of the Dialysis Communication Form from 05/01/2026 through 08/03/2026 revealed 41 dialysis communication sheets, and post-dialysis documentation was missing on 25 dates. The facility’s staff stated the resident would be assessed upon return from dialysis and documented on the dialysis communication sheet, and administrative staff stated the charge nurse was expected to complete and document the post-return assessment. The facility’s Hemodialysis policy stated it would provide care and treatment consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the resident’s goals and preferences.
Missed Dialysis Transport for Resident Requiring Hemodialysis
Penalty
Summary
The facility failed to ensure a resident who required hemodialysis was transported to treatment. Resident #106 was admitted with diagnoses including dependence on renal dialysis, end stage renal disease, type 2 diabetes mellitus with diabetic neuropathy, and hypertensive heart and chronic kidney disease with heart failure and end stage renal disease. The care plan identified that he was dependent on dialysis and received hemodialysis three times a week. He had a BIMS score of 13, indicating no cognitive impairment, and was dependent on staff for activities of daily living with impaired upper and lower extremities bilaterally. After the resident returned from the hospital, physician orders continued hemodialysis three times weekly with a 6:15 A.M. pickup time and instruction to be in the lobby at 5:15 A.M. On the morning of the missed treatment, the resident was observed waiting in his wheelchair in the lobby and later stated he was waiting for dialysis transport. Staff later told him he had missed the appointment because transportation had not been set up. The SSD stated it was the facility's responsibility to call and alert the dialysis center of updates, including hospitalizations. The RT stated the dialysis transport was automatic, but when the resident transferred to the hospital the facility did not update the dialysis center, and the center stopped coming after unsuccessful pickup attempts. The facility's dialysis transfer agreement stated it was responsible for arranging transportation to and from the dialysis center, and the dialysis monitoring policy stated the facility would maintain the safety and health of residents receiving dialysis services.
Failure to Monitor Fluid Restriction for a Resident Receiving Dialysis
Penalty
Summary
The facility failed to monitor the fluid restriction for Resident 10, who was admitted and readmitted to the facility with diagnoses including ESRD, dependence on renal dialysis, and pleural effusion. The resident’s MDS dated 6/26/2026 indicated moderate cognitive impairment and dependence for multiple activities of daily living, with setup or clean-up assistance needed for eating and oral hygiene. A physician order dated 7/10/2026 specified a fluid restriction of 1200 ml per day, but during review of the MAR on 7/23/2026, there was no documentation of the resident’s oral intake to show that the restriction was being monitored. The RNS stated she could not find any documentation of oral intake monitoring and also stated the resident did not have a care plan reflecting the 1200 ml fluid restriction. The facility’s P&P for Fluid Restriction required intake and output documentation and a plan of care for residents on fluid restrictions, and the Dialysis Management P&P stated that diet and fluid restrictions would be followed as ordered and documented in the medical record.
Failure to Follow PD Disconnect Procedure
Penalty
Summary
The facility failed to implement care consistent with professional standards of practice to prevent potential complications from a dialysis access site for one resident receiving peritoneal dialysis. The facility’s procedure for disconnecting PD directed staff to close the resident’s door, apply a mask, and then wash hands and apply gloves before accessing the PD port. During observation of the resident’s PD disconnecting procedure, a registered nurse placed gloves on without performing hand hygiene, entered the resident’s room without closing the door, and then applied a mask from the resident’s bedside table while continuing the procedure with the same gloves. The record also showed that the nurse had not received any facility training related to the resident’s PD.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release October 8, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.