Failure to Assess and Maintain Dialysis Access Site Dressings for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide safe and appropriate dialysis care by not adequately assessing, documenting, or managing bleeding and dressings at dialysis access sites for two residents. One resident with end-stage renal disease, anemia in chronic kidney disease, and dependence on renal dialysis had orders for hemodialysis three times weekly and for staff to check the dialysis access site every shift for bruit and thrill, record and report abnormalities immediately, and reinforce the dressing as needed. The resident’s care plan also directed staff to check and change the dressing daily at the access site and document. When the resident’s left upper arm AV fistula site was observed, the dressing was undated, completely saturated with dried dark brown drainage, and the tape was loose and nearly falling off. The resident reported that the dressing had been bloody since the last dialysis treatment several days earlier and that she received dialysis on a Monday/Wednesday/Friday schedule. The LPN assigned to the resident that morning stated she had started her shift at 7 AM, administered morning medications, and had not assessed the dialysis access site prior to the surveyor’s observation. Upon removing the dressing, the LPN observed that it was saturated with dried dark brown drainage and acknowledged it was most likely the same dressing applied at the dialysis center on the prior treatment day. The LPN stated that the dialysis center changes the dressing and that unit nurses reinforce dressings as needed. Review of the Dialysis Communication Report for the resident showed instructions to monitor for bleeding from the access site post-treatment. However, nursing progress notes for the days surrounding the observed condition did not contain documentation of bleeding at the dialysis access site or any notification to the dialysis center or physician, despite the resident’s report that the dressing had been bloody since the prior dialysis session. A second resident with severe cognitive impairment, hemiplegia, chronic kidney disease stage 4, and dependence on renal dialysis received weekly offsite dialysis via a right chest central venous catheter. Physician orders directed staff to check the catheter site daily and upon return from dialysis, ensure caps were secure, and reinforce the dressing as needed. The resident’s care plan required staff to check and change the dressing daily at the access site and document. During observation, a gauze dressing was seen hanging loosely under the resident’s shirt, with the dialysis catheter site exposed and dry, crusted brownish substance around the insertion site. The RN present stated the site had been checked that morning and suggested the dressing may have come off when the CNA changed the resident’s clothes. The DON later stated that catheter dressings are done at the dialysis center, but if the dressing comes off it should be reinforced by the nurse on duty and that the catheter site should always be covered. The facility’s Dialysis Protocol required that dialysis sites be checked every shift for signs of infection or bleeding and monitored every shift for thrill and bruit, and allowed line dressings to be reinforced at the facility, but these expectations were not met for the two residents.
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