Failure to Perform and Document Pre/Post-Dialysis Assessments and AV Fistula Site Care
Penalty
Summary
The deficiency involves the facility’s failure to provide hemodialysis care and services consistent with professional standards of practice for a resident with End Stage Renal Disease who was dependent on renal dialysis. The resident had an AV fistula in the right upper arm and standing orders for hemodialysis three times weekly, as well as an order directing staff to apply pressure and notify the MD if bleeding occurred at the AV shunt after dialysis. The resident’s care plan required staff to check and change the dressing daily at the access site, document this care, and monitor, document, and report signs and symptoms of infection and other complications. However, review of the medical record showed that pre- and post-dialysis evaluations were not consistently completed by licensed nurses on multiple dates when the resident had dialysis appointments. Dialysis documentation from the dialysis unit showed repeated comments over several weeks that the dressing on the hemodialysis access was being left on after treatment and not removed at the facility. Entries included notations that the dressing had been left on since prior treatments, that it must be removed to prevent clotting or damage to the access, and that dressings from prior dates remained in place. On one date, the dialysis staff documented that a dressing left on since a previous treatment was damp and had left raw skin and soreness at the access site. A subsequent wound culture from the access site grew heavy Pseudomonas aeruginosa and moderate Staphylococcus aureus, and the physician ordered antibiotics including Vancomycin and Ceftazidime. Despite this, there was no documentation in the facility record that the access site was monitored for infection after the positive culture and initiation of new antibiotic therapy. Interviews with multiple licensed nurses and the DON confirmed gaps and inaccuracies in assessment and documentation. One nurse acknowledged signing post-dialysis evaluations without documenting removal of the dialysis dressings. Another nurse acknowledged that pre-dialysis assessments documented the access site as within normal limits even though the electronic record offered more specific options such as redness, swelling, pain, bleeding, or skin discoloration, and that these more accurate descriptors were not selected. This nurse also stated she was unaware that the dressing on the AVF site was from the previous dialysis session and confirmed that no observations were done to monitor for signs of inflammation, infection, or to inspect the shunt site for color, warmth, redness, edema, and drainage. A third nurse confirmed that on several dates when she was assigned to the resident, pre- or post-dialysis assessments were not performed, and she had assumed the dressings on the AVF site were for facility-provided treatment. The DON confirmed that post-dialysis dressings should be removed within a specified time frame and that the dialysis center had communicated multiple times that the resident was returning with dressings still in place from prior treatments, contrary to facility policies requiring daily assessment and inspection of the AV shunt site once per shift.
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