Failure to Ensure Monitoring and Orders for Dialysis Care After Hospital Readmission
Penalty
Summary
The facility failed to ensure appropriate monitoring and care for a resident with end stage renal disease who was dependent on hemodialysis. The resident had a care plan and physician orders in place that required specific interventions, including checking the dialysis fistula site for infection, monitoring vital signs before and after dialysis, obtaining post-dialysis weights, and assessing the fistula for bruit and thrill every shift. Despite these orders, the clinical record lacked documentation of any physician dialysis orders following the resident's readmission from the hospital, covering a period from 11/15/25 to 12/10/25. Observations confirmed the presence of a dialysis fistula, and interviews with facility leadership acknowledged that dialysis orders should have been reinstated upon the resident's return from the hospital. The absence of documented dialysis orders and related monitoring during this period indicated a failure to provide safe and appropriate dialysis care and services as required by the resident's condition and care plan.