Failure to Maintain Orders, Care Plans, and Assessments for Dialysis Services
Penalty
Summary
The deficiency involves the facility’s failure to provide dialysis services consistent with professional standards, physician orders, and person-centered care plans for two residents receiving hemodialysis. One resident with end stage renal disease (ESRD), dependence on renal dialysis, and lobar pneumonia had a baseline care plan that did not address hemodialysis or ESRD, and the care plan only referenced an acute infection without further specification. This resident’s PPS 5-day MDS showed severely impaired cognition but no behaviors or refusal of care. Review of the Pre/Post Dialysis Communication Report forms for this resident in December showed missing post-dialysis assessments on multiple dates, and the order summary report showed no physician orders for hemodialysis or for inspection of the vascular access site. The second resident, also with ESRD, dependence on renal dialysis, and type 2 diabetes mellitus, had an MDS indicating moderately impaired cognition and no behaviors or refusal of care. This resident’s care plan included hemodialysis but did not specify the frequency, location, or access site. Review of this resident’s Pre/Post Dialysis Communication Reports showed only a limited number of forms for December and January, despite the expectation of thrice-weekly dialysis, and the order summary report likewise showed no physician orders for hemodialysis or vascular access site inspection. Thus, for both residents, required dialysis-related assessments and orders were incomplete or absent. Interviews with facility staff further described gaps in the dialysis care process. The ADON stated there was no dialysis policy and that staff were expected to follow standards of care, confirming that both residents received dialysis three times weekly and that nurses were responsible for completing pre- and post-dialysis assessment forms, but acknowledged the process was not monitored and that nursing leadership had assumed someone else was responsible. An RN reported that the admission checklist did not include dialysis and that staff turnover and ongoing orientation contributed to uncertainty about who completed the dialysis assessment forms, while also stating that the IDT was responsible for care plans. An LVN stated she was unaware that dialysis orders were not in the computer and did not know who monitored the pre/post dialysis form process. The attending physician stated that not following standards of care for dialysis recipients could eventually lead to complications, and the Administrator confirmed there was no dialysis policy and that he expected nursing staff and management to ensure dialysis orders, care plans, and post-dialysis assessments were completed and monitored.
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