F0698

D

Failure to Obtain and Implement Orders for Assessment of Maturing A/V Fistula in Dialysis Resident

Burgaw, North Carolina Survey Completed on 01-15-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to obtain and implement provider orders to assess and manage a maturing right upper extremity arteriovenous (A/V) fistula for a resident with end stage renal disease who was dependent on dialysis. Hospital records dated 12/08/25 documented that the resident had an A/V fistula placed in October 2025 in anticipation of dialysis, which was positive for bruit and thrill but not yet mature, and that a permacath was placed during that hospitalization. On admission and readmission to the facility in December 2025 and January 2026, the resident’s diagnoses included end stage renal disease with dependence on renal dialysis, and the Minimum Data Set reflected that the resident was receiving dialysis services. The care plan dated 12/17/25 identified risk for complications related to dialysis and included interventions such as not drawing blood or taking blood pressure in the arm with the fistula, observing for signs of infection, palpating for thrill, and listening for bruit, with instructions to report abnormalities to the physician.

Despite these care plan interventions, the physician orders written on 12/18/25 and again on 01/11/26 addressed only the permacath, specifying dialysis days and monitoring the catheter site for bleeding, infection, and intact caps, with no orders to assess or protect the right arm A/V fistula. Nursing documentation, including skilled care notes and skin assessments, repeatedly acknowledged the presence of the right upper arm A/V fistula and described it as positive for bruit and thrill or as a dialysis access, while also noting the right chest permacath. The Medication Administration Records for December 2025 and January 2026 showed that staff were documenting assessments of the permacath site but contained no orders or documentation for assessment of the A/V fistula site.

Interviews with staff confirmed that no orders were initiated for the A/V fistula on either admission. One nurse stated she assessed the A/V fistula and found a positive bruit and thrill but did not enter any orders, explaining that unit managers usually entered “batch orders” for A/V fistulas, which would include assessing bruit and thrill, monitoring for infection, and restricting blood pressures and lab draws in the affected arm. The unit manager, wound treatment nurse, nurse practitioner, and DON each acknowledged awareness of the A/V fistula’s presence, with some staff mistakenly believing it was an old, non-functioning access and others stating that admitting nurses should have initiated batch orders for the maturing fistula. The DON and unit manager confirmed that orders to assess the A/V fistula site were not entered on either admission, despite expectations that such orders should have been in place.