Failure to Provide Safe and Appropriate Dialysis Care and Services
Penalty
Summary
Facility staff failed to provide appropriate dialysis care and services for three residents requiring dialysis. For one resident, there was no physician order for staff to monitor the dialysis fistula site in the left upper arm following readmission from the hospital. The resident reported that only dialysis staff checked the site, and facility staff rarely did so. A review of the clinical record confirmed the absence of orders for monitoring the fistula site, and staff interviews revealed that the omission was due to the admitting nurse forgetting to add the order upon readmission. Another resident did not have transportation arranged to attend scheduled dialysis appointments. The administrator stated that the facility was unaware the resident was a dialysis patient upon admission and encountered difficulties arranging stretcher transport and coordinating with the dialysis center. The director of nursing and transport coordinator confirmed that no transport was set up for the resident at the required time, and there was no documentation of transport arrangements for that period. For a third resident, staff failed to monitor the dialysis access port according to professional standards and did not notify the medical provider when the resident declined a dialysis session. The clinical record only noted the presence of a fistula in the admission assessment and care plan, with no documentation of regular monitoring for thrill and bruit or related physician orders. When the resident refused dialysis due to feeling unwell, staff did not inform the medical provider, despite acknowledging the importance of such notification. Interviews and record reviews confirmed the lack of documentation and communication regarding the missed dialysis session and access site monitoring.