F0698

E

Failure to Assess and Monitor Dialysis Resident Before and After Treatments

Hollis, Oklahoma Survey Completed on 01-08-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to assess and monitor a dialysis-dependent resident before and after dialysis treatments, contrary to its own dialysis policy. The undated dialysis policy required nursing staff to monitor residents before and after dialysis, protect and observe dialysis access sites for signs of infection or complications, and document all dialysis-related care, observations, and communications in the medical record. The resident’s care plan, initiated for end-stage renal disease with scheduled dialysis on Tuesday, Thursday, and Saturday, included goals to manage the condition and ensure safe transport to and from dialysis. The admission assessment documented that the resident had intact cognition with a BIMS score of 13 and received dialysis services.

Record review showed no nursing monitoring documented before or after multiple scheduled dialysis treatments on 12/16/25, 12/18/25, 12/20/25, 12/23/25, 12/26/25, 12/27/25, 12/30/25, 01/02/26, 01/03/26, and 01/06/26. During interviews, the resident reported attending dialysis three times weekly, being transported by a transportation company during the week and by family on weekends, and stated that facility nurses did not look at the dialysis shunt site or assess them before or after dialysis. Observation confirmed the presence of a dialysis shunt on the resident’s left forearm. An RN stated they did not assess the resident before or after dialysis unless the resident felt unwell or had abnormal blood pressure, and that the shunt was assessed only if there was a concern. The DON stated that nurses should assess the resident upon return from dialysis and document findings in the nurse’s notes.