F0698

D

Failure to Document Required Dialysis Permacath Assessments Each Shift

Tulsa, Oklahoma Survey Completed on 11-25-2025

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that a resident’s dialysis permacath was assessed and documented every shift as required by physician orders and facility policy. The facility’s dialysis policy directed that fistula/shunt sites be checked every shift for bruits, bleeding, increased pain, and signs of infection. A physician order for one resident specified that the right upper chest permacath was to be monitored for bleeding and an intact dressing every shift, with the dialysis center to be notified of any concerns. The resident’s September 2025 Treatment Administration Record (TAR) showed that the permacath was scheduled to be assessed once each shift for bleeding and dressing integrity.

Record review of the September 2025 TAR revealed missing documentation of these required assessments on four of the 46 scheduled assessment times: two shifts on one date and single shifts on two other dates. During interview, an LPN explained that they assessed the resident’s chest catheter every shift and before dialysis and documented these checks on the TAR, but upon reviewing the TAR acknowledged that four entries were not documented. The LPN stated they had worked some of those shifts, believed they had performed the checks, and suggested they may have pressed the wrong button in the electronic system, acknowledging they should have ensured the documentation was present. The DON, after reviewing the TAR, stated that nurses enter assessment information into the EMR, expressed confidence that the assessments were done, but acknowledged there was no documentation to prove it and believed a nurse error occurred when entering the information, recognizing the importance of both the assessments and their documentation.