Failure to Assess and Care Plan for New Dialysis Access Infection
Penalty
Summary
The deficiency involves the facility’s failure to ensure licensed nurses were competent in providing quality care by not completing a comprehensive assessment and individualized care plan for a resident who developed a new infection at a dialysis access site. The resident was admitted with end stage renal disease and dependence on hemodialysis, with orders for dialysis three times weekly and specific instructions for managing bleeding at the arteriovenous fistula in the right upper arm. A microbiology report dated 1/24/26, from a wound culture collected at the access site, showed heavy growth of Pseudomonas aeruginosa and moderate growth of Staphylococcus aureus, and the physician ordered Vancomycin and Ceftazidime. Despite these findings and the initiation of antibiotic therapy, the medical record contained no documentation of a comprehensive assessment, no individualized care plan with interventions related to the new onset infection, and no monitoring for signs and symptoms of infection or complications. Interviews and record reviews further confirmed that required change-of-condition procedures were not followed. One licensed nurse acknowledged there was no change-of-condition documentation in the resident’s record related to the positive culture results and antibiotic therapy and stated that a change of condition should have been initiated but was not. Another licensed nurse, who was assigned to and familiar with the resident, confirmed that the receiving nurse did not initiate a change of condition when dialysis staff communicated that the resident had positive bacterial cultures and was receiving antibiotics. This was inconsistent with the facility’s “Change in Condition” policy, which requires the licensed nurse to assess the change, determine appropriate nursing interventions, and notify the physician/APP with a summary of the condition change, vital signs, and focused system review, including reporting laboratory and diagnostic results.
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