Failure to Provide Timely Dialysis Port Care
Penalty
Summary
The facility failed to ensure that a resident requiring hemodialysis received care consistent with professional standards and the resident's care plan. Specifically, the facility did not remove the dialysis port dressing as ordered by the dialysis center on multiple occasions, despite repeated instructions from the dialysis center to remove the dressing within 2-4 hours after dialysis. Documentation from the dialysis center indicated that the bandages were not removed by facility staff before the resident's next dialysis treatment, and this issue was communicated to the facility several times through written notes and direct notifications to the charge nurse. The resident involved had end stage renal disease, type 2 diabetes, and schizophrenia, and was cognitively intact. The care plan included monitoring the dialysis access site for signs of infection and encouraging attendance at dialysis appointments, but did not include specific interventions for removing or changing the port-access dressings. Multiple records from the dialysis center documented that the dressings were left in place, sometimes covered with additional dressings, leading to swelling, pain, bleeding, and skin damage at the access site. The dialysis center staff reported providing education to the facility staff about the importance of timely dressing removal, but the problem persisted over several weeks. Interviews with facility staff revealed inconsistent understanding of the procedures for dialysis port care. Some nurses stated that the dressing should be removed and the port left open to air after dialysis, while others were unsure about the correct protocol. Several staff members did not know the resident or were not aware of the specific requirements for dialysis port care. The facility's policy referenced providing routine AV shunt care per physician orders, but the observed practice did not align with the instructions provided by the dialysis center.