F0656

D

Failure to Care Plan for New Dialysis Port Catheter

Los Angeles, California Survey Completed on 02-04-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered care plan with measurable objectives and timetables to address a resident’s left upper chest port catheter used for renal dialysis. The resident was originally admitted with diagnoses including dementia, dependence on renal dialysis, and stage four chronic kidney disease, and was later readmitted after a hospitalization during which the dialysis access was changed from an arteriovenous fistula to a left upper chest port catheter. The resident’s history and physical documented fluctuating capacity to understand and make decisions, and the Minimum Data Set showed severely impaired cognitive functioning and dependence on staff for eating, oral care, toileting hygiene, showers, personal hygiene, and dressing.

During concurrent interview and record review, RN 1 confirmed that the resident’s care plan did not include any plan for care and monitoring of the left upper chest port catheter and had not been updated upon readmission to reflect the new dialysis access site. RN 1 stated that the care plan should have been updated to address the accurate dialysis access site to provide proper monitoring. The DON also stated that the care plan should have been developed upon admission to address the new renal dialysis access site and how to manage and care for it, and acknowledged that the resident’s care plan was not person-centered and complete because it lacked a plan for the dialysis access site. The facility’s policy on Comprehensive Care Plans required development and implementation of a comprehensive person-centered care plan with measurable objectives and timeframes to meet identified medical, nursing, mental, and psychosocial needs, including services to attain or maintain the resident’s highest practicable well-being.