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:
A resident with ESRD, renal osteodystrophy, and dialysis dependence did not receive prescribed phosphorus binders as ordered. Velphoro was not given for an entire month and Sevelamer was given on only a few days, with charting repeatedly stating the meds were awaiting pharmacy delivery or unavailable. Staff gave inconsistent explanations, and the dialysis center manager stated the resident had not been receiving the meds as prescribed and that Sevelamer should have been discontinued.
A resident with ESRD, CHF, and DM2 had orders for dialysis three times weekly, and the care plan called for open communication with the dialysis center. However, multiple dialysis communication sheets were missing from the clinical record even though the MAR showed the resident went to dialysis on those visits, and the DON confirmed the records were absent.
Incomplete dialysis communication and access site monitoring: The facility failed to maintain complete dialysis communication records for three residents with ESRD or dialysis dependence, and failed to document ordered AV fistula checks for two residents. One resident had conflicting AV fistula orders, while another had repeated missing thrill and bruit documentation on the TAR. The DON and NHA confirmed the documentation failures.
A facility failed to complete required dialysis-related care for three residents receiving hemodialysis. For one resident, the AV shunt was not assessed and documented before and after dialysis on multiple occasions. For two other residents, ordered I&O monitoring was not consistently recorded each shift, and one resident’s CBC and BMP were completed monthly instead of weekly as ordered by the MD.
A resident with ESRD and diabetes received dialysis, but staff failed to monitor the dialysis access correctly after the resident’s access changed from a CVC in the right chest to an AV fistula in the left upper arm. Nursing staff documented checks for bleeding and post-dialysis status, but were not aware of the fistula, did not assess for bruit and thrill, and did not have direction to avoid BP checks on the access arm. The DON stated staff should know the correct access site and assess it based on the type and location of access.
The facility failed to provide consistent dialysis-related care for two residents with ESRD. One resident missed scheduled dialysis because transportation did not arrive, and staff did not complete the dialysis communication record with pre- and post-dialysis assessments. Another resident had missing dialysis sign-out documentation, a missing dialysis communication record entry, and exceeded a physician-ordered 1000 ml fluid restriction on multiple days, while staff and the resident stated the restriction was not known to them.
Missed Phosphorus Binder Medications for Dialysis Resident
Penalty
Summary
The facility failed to ensure safe, appropriate dialysis-related care and medications were provided for a resident with end stage renal failure, renal osteodystrophy, disorders of phosphorus metabolism, and dependence on dialysis treatments. The resident had physician orders for Velphoro 500 mg daily and Sevelamer Carbonate 800 mg, 2 tablets with meals, both used to control phosphorus levels. The resident was admitted after hospitalization for multiple falls and generalized muscle weakness, and at discharge had a phosphorus level of 4.6, which was noted as high. Record review showed the resident did not receive Velphoro for the entire month of June 2026 and July 2026, and Sevelamer was administered on only seven of the 24 days the resident was present in June 2026. Progress notes repeatedly documented that the medication was awaiting pharmacy delivery or was not available, including multiple dates in June and July, and the MAR referenced missing doses as “see progress notes” without corresponding documentation. During interviews, a nurse stated she did not know why the medication had not been sent and had placed it on hold, while the pharmacy tech stated Velphoro was not received through the pharmacy and was available through the dialysis center. The dialysis center clinical manager stated she was unaware the resident had not been receiving the medication as prescribed, said Velphoro comes to the center and is then sent to the facility, and stated Sevelamer should have been discontinued.
Incomplete Dialysis Communication Records
Penalty
Summary
The facility failed to maintain complete and accurate dialysis communication records for one resident with end stage renal disease (ESRD), chronic systolic congestive heart failure, and diabetes mellitus type II. The resident had physician orders for dialysis treatments three times a week on Monday, Wednesday, and Friday, and the care plan included keeping open communication with the dialysis center. Facility policy stated that agreements with the contracted ESRD facility include how information will be exchanged between the facilities. Review of the resident’s dialysis treatment communication sheets showed multiple missing sheets for dialysis visits across March, April, May, and June 2026. Review of the MAR confirmed the resident went to dialysis on those dates. During interview, the DON confirmed the missing dialysis communication sheets were not present in the clinical record and stated that dialysis consult sheets should be completed with each dialysis treatment and kept in the record.
Incomplete dialysis communication and access site monitoring
Penalty
Summary
The facility failed to provide consistent and complete communication with the dialysis center for three residents who required dialysis services. Resident R17 had ESRD, was ordered to receive hemodialysis Monday, Wednesday, and Friday, and had a care plan calling for dialysis communication and monitoring of the AV fistula. The resident’s clinical record did not include complete dialysis communication forms on six dates between 5/1/26 and 6/22/26, and an LPN confirmed the missing documentation during interview. Resident R34 had ESRD and was ordered to send a communication binder to dialysis on Tuesday, Thursday, and Saturday, with communication sheets completed upon return every day and evening shift; the dialysis communication record was incomplete on 6/9/26, 6/11/26, and 6/13/26. Resident R86 had quadriplegia, diabetes mellitus, and dependence on renal dialysis, with orders for dialysis Monday, Wednesday, and Friday and to send the dialysis communication book on dialysis days; the communication binder was incomplete on 6/10/26, 6/15/26, 6/20/26, and 6/22/26. The facility also failed to ensure accurate and complete monitoring of dialysis access sites for two residents. Resident R17 had conflicting physician orders identifying both right and left AV fistula monitoring, and the DON stated the resident had a fistula in the left arm and that the orders were updated to be accurate. The June 2026 TAR did not show documentation that the ordered AV fistula checks for bruit and thrill were completed or refused on multiple shifts. The DON confirmed the facility failed to ensure monitoring of Resident R17’s dialysis access site was accurate and complete. Resident R86 had a physician order for right AV fistula thrill checks every shift and bruit checks every shift, with notification to the physician if not present. The June 2026 TAR did not show documentation that thrill or bruit checks were signed off or refused on multiple daylight shifts and on two evening shifts. During interview, the DON confirmed the facility failed to document dialysis-specific care as ordered for Resident R86. The NHA and DON later confirmed that the facility failed to provide consistent and complete communication with the dialysis center for all three residents and failed to ensure access site monitoring was completed for two of the three residents.
Dialysis care, I&O monitoring, and ordered labs not completed
Penalty
Summary
The facility failed to provide dialysis care and services in accordance with its policy for three residents receiving hemodialysis. For one resident with ESRD, anemia, and dementia, the care plan directed staff to assess the left upper arm AV shunt for redness, swelling, warmth, exudate, tenderness, bruit, thrill, and bleeding, and to document the resident’s condition before and after dialysis. The resident’s dialysis communication record showed that the AV shunt check was not completed on two post-dialysis dates and two pre-dialysis dates. During interviews, nursing staff stated the form was not filled out completely and that the access site should have been assessed and documented before leaving for dialysis and upon return. For a second resident with type 2 DM, ESRD, and dependence on renal dialysis, the care plan directed staff to monitor intake and output every shift. Review of the intake and output record and the electronic chart showed that urine output was not documented for one overnight shift. Nursing staff confirmed there was no documented urine output for that shift and that it should have been recorded per the care plan and facility policy. For a third resident with ESRD, dependence on renal dialysis, and anemia, the care plan directed staff to monitor intake and output every shift and to complete laboratory testing as ordered. Review of the records showed multiple shifts with no documented output, and the resident’s CBC and BMP were completed monthly rather than weekly as ordered. Nursing staff and the DON stated the resident should have had I&O monitoring every shift and weekly labs completed as ordered, and that the order should have been followed or clarified with a new order.
Dialysis Access Monitoring Not Performed Correctly
Penalty
Summary
The facility failed to provide appropriate monitoring of a resident’s dialysis access site for one resident who required dialysis services. The resident had intact cognition, diabetes mellitus, and end stage renal disease, and the care plan directed staff to monitor the central dialysis catheter port site for bleeding every shift. Provider orders included review of post-dialysis treatment reports, monitoring the dialysis site for bleeding, and vital signs after dialysis, but did not include monitoring for bruit and thrill or direction to avoid blood pressures on the left arm despite the resident having an AV fistula. Documentation showed the resident’s dialysis access changed from a right chest CVC to a left upper arm AV fistula, with the CVC later removed and the AV fistula confirmed as usable for dialysis. During interviews, nursing staff stated they assessed vital signs, weight, and the dialysis site for bleeding, but were not aware of the AV fistula or the need to assess bruit and thrill and avoid blood pressures on the access arm. The DON stated nurses should know the correct location of the resident’s dialysis access site and assess complications and care according to the type and location of access. The facility policy required assessment before and after dialysis for infection and patency of fistula or graft, including feeling for a thrill, listening for a bruit, and not taking blood pressures on the access arm.
Dialysis care, transportation, documentation, and fluid restriction failures
Penalty
Summary
The facility failed to ensure safe, appropriate dialysis care for two residents who required hemodialysis. One resident had diagnoses including ESRD, metabolic encephalopathy, and diabetes, and the record showed he was readmitted to the facility with a care plan and physician orders for dialysis on Tuesday, Thursday, and Saturday, including assistance with curbside pickup for dialysis transportation. The resident also had an H&P stating he had the capacity to make and understand complex decisions and an MDS indicating he required supervision for ADLs and received dialysis. For this resident, the record showed a routinely scheduled dialysis appointment was missed because transportation did not arrive. The progress note stated the facility Medical Director was informed and that staff would follow up to schedule a same-day make-up dialysis appointment. The record then showed a make-up dialysis was scheduled, but the resident did not go and was instead transferred to an acute care hospital for missed dialysis. During interview, staff stated the resident missed dialysis because transportation was not arranged, and the DON acknowledged the missed dialysis sessions were due to transportation issues. Review of the dialysis communication record also showed no pre- or post-dialysis assessments documented for the make-up dialysis, and staff stated the form should have been completed before departure and upon return. The second resident had ESRD and dependence on hemodialysis, with physician orders for dialysis three times weekly, notification of abnormalities before and after dialysis, post-dialysis weights, and a fluid restriction of 1000 ml per day. Review of the dialysis communication record showed one dialysis date was missing from the facility documentation, and staff confirmed the resident had completed dialysis that day. Progress notes also lacked documentation showing the resident left the facility for multiple dialysis appointments, and staff validated the missing sign-out documentation. In addition, the resident’s fluid intake record showed intake above the ordered 1000 ml limit on several dates, and staff stated the resident was supposed to be on the restriction. The resident and CNA stated they did not know the resident was on a 1000 ml fluid restriction.
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