Failure to Perform and Document Pre- and Post-Dialysis Assessments
Penalty
Summary
The facility failed to ensure a resident who required dialysis received ongoing assessments of condition before and after dialysis treatments, as required by facility policy and physician orders. The resident had been admitted with multiple diagnoses including end stage renal disease, diabetes mellitus, dependence on renal dialysis, morbid obesity, COPD, and CHF, and received dialysis three times per week at an off-site location. The care plan noted the resident frequently refused dialysis and included interventions such as monitoring lung sounds, edema, shunt site, bruit and thrill, and maintaining communication with the dialysis center. Physician orders included checking the left arm AV fistula for bruit and thrill every shift and documented the scheduled dialysis days and times. Medical record review revealed no evidence that the facility completed pre-treatment or post-treatment assessments related to the resident’s dialysis sessions. Although the dialysis center’s communication forms from several months documented pre- and post-treatment weights, vital signs, condition, and medications administered, these were completed by the dialysis center, not the facility. An LPN reported that the resident had a binder taken to dialysis and that she filled out a form with vital signs and any signs or symptoms of pain or sickness, but she could not produce the binder or a sample of the form. The DON confirmed she was unable to locate any pre- or post-dialysis assessments completed by facility staff and verified that the available communication forms were from the dialysis center, not the facility, despite the facility’s Dialysis Management policy requiring assessment and monitoring for complications.
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