Failure to Implement Hemodialysis Care Plan and Timely Hospice Care Planning
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident with end-stage renal disease who required hemodialysis and had a left upper arm arteriovenous (AV) fistula. The resident had a documented history of removing her pressure dressing prematurely after dialysis, resulting in previous bleeding episodes. Despite care plan interventions specifying that the dressing should remain in place for at least four hours post-dialysis and that the access site should be monitored for bleeding, redness, swelling, and pain upon return from dialysis, staff did not perform or document a post-dialysis assessment or direct inspection of the AV fistula site after the resident returned from treatment. The resident was also on Eliquis, an anticoagulant, further increasing her risk for bleeding. On the day of the incident, the resident returned from hemodialysis and was assisted to her room by an RN, who did not visually inspect the AV fistula site or check vital signs, assuming the site was not bleeding because the clothing was not wet. The RN did not inform other staff of the resident's return, and both the assigned LVN and CNA were on lunch breaks and unaware of the resident's status. Approximately 30 minutes later, the CNA discovered the resident unresponsive and actively bleeding from the AV fistula site, with the pressure dressing removed and blood present on the bed and floor. Emergency services were called, but the resident was pronounced deceased shortly after their arrival. Interviews and record reviews confirmed that the required post-dialysis assessment was not completed, and there was no documentation of monitoring or care provided to the AV fistula site upon the resident's return. The care plan interventions related to hemodialysis and AV fistula monitoring were not implemented, and staff failed to communicate and coordinate care as required. Additionally, the facility failed to promptly develop and implement a person-centered care plan for another resident admitted to hospice, resulting in a delay in care planning.
Removal Plan
- The DON conducted a comprehensive review of Resident 1's hemodialysis-related care upon Resident 1's return from the hemodialysis treatment, including interviews with assigned nursing staff, review of policy and procedure on Dialysis Care, forms used for dialysis care, nurses progress notes, and communication related to Resident 1's return from dialysis. Failures related to post-dialysis assessment, monitoring, communication, and documentation were identified.
- All residents returning from hemodialysis treatment or any off-site procedure will be assessed upon return at the soonest practicable time by the Charge Nurse and/or RN. The assessment will include direct inspection of the hemodialysis access site, vital signs, bleeding assessment, condition of the resident, documentation of findings in the nursing progress notes, and the Nursing Facility Post Dialysis Assessment form. The CNA will immediately notify any licensed nurse of any observed signs of bleeding or distress and will endorse findings to the LVN Charge Nurse and/or RN.
- The RN Supervisor and Charge Nurse reviewed and updated the person-centered care plans for residents receiving hemodialysis (Residents 2, 3, 4, 5, 6, 7, 8, and 9) to reflect each resident's individual needs and the required care of their dialysis access sites.
- The DON and Medical Records staff conducted an audit on the Nursing Facility Pre and Post Dialysis Assessment forms for eight residents (Residents 2, 3, 4, 5, 6, 7, 8, 9) receiving hemodialysis treatment. There were no other residents identified with deficiencies similar to those found for Resident 1.
- The DON and RN Supervisor conducted an audit of care plans related to dialysis care and the Nursing Facility Post Dialysis Assessment form for eight residents (Resident 2, 3, 4, 5, 6, 7, 8, and 9) receiving hemodialysis. The audit showed that all applicable care plan interventions were present and up to date for Residents 2, 3, 4, 5, 6, 7, 8, and 9.
- The DON and DSD provided in-service training to nursing staff regarding care planning, with emphasis on: a) Implementation of residents' individualized hemodialysis care plans; b) Completion of the Nursing Facility Post-Dialysis Assessment form, the Dialysis Flow Sheet-Return Assessment and nursing progress notes documenting the date and time residents returned to the facility, to be completed by LVNs or RNs following hemodialysis treatment; c) Comprehensive assessment and monitoring of residents by LVNs or RNs following dialysis treatment.
- The DON provided a one on one in-service to RN 1 and LVN 1, who were assigned to Resident 1 during the 3 p.m. to 11 p.m. shift regarding P&P on Dialysis Care. The in-service addressed conducting pre and post dialysis assessments with focus on assessing the dialysis access site for signs of bleeding, resident's medical condition and other complications. The in-service addressed documentation on the nurse's progress notes and the Nursing Facility Pre and Post Dialysis Assessment form. Licensed nurse will document in the nurse's progress notes resident's return to the facility from the hemodialysis treatment, including the date and time of the return and the care provided to the resident.