Failure to Assess and Document Dialysis Access Sites
Penalty
Summary
Facility staff failed to assess, observe, and document the care of a resident's left arm fistula site and external central venous catheter (CVC) dialysis access site. The resident, who had diagnoses including end stage renal disease, dialysis dependence, diabetes, and heart disease, was admitted with both a CVC in the left upper chest and a fistula in the left arm. Despite physician orders for dialysis three times weekly and the presence of both access points, there was no documented evidence in the resident's orders, medication administration record, treatment administration record, progress notes, or care plan that staff assessed or monitored either the CVC or fistula. Interviews confirmed that the resident regularly attended dialysis and had both access sites in place for several months. Direct observation verified the presence of both the fistula and the CVC, with appropriate dressings in place. The Director of Nursing acknowledged that the medical record did not reflect any assessment or monitoring of the dialysis access sites. Facility policy required ongoing assessment and oversight of residents before, during, and after dialysis, including monitoring for complications and infection control, but this was not documented for the resident in question.