F0698

G

Failure to Ensure Safe Peritoneal Dialysis and Supply Management

Fort Worth, Texas Survey Completed on 02-07-2026

Penalty

Fine: $19,115

Summary

The deficiency involves the facility’s failure to ensure that a resident requiring peritoneal dialysis (PD) received dialysis services consistent with professional standards of practice. The resident was an adult female with end-stage renal disease, prior possible peritonitis, stroke, type 2 diabetes, and heart failure, who was admitted with an active need for PD from 6 p.m. to 6 a.m. Her care plan identified dialysis needs and directed staff to monitor the PD catheter site for redness or drainage, report cloudy effluent, inadequate drainage or inflow problems, sudden weight changes, shortness of breath, abdominal pain, fever, and signs of infection. The care plan also documented that PD would be completed independently by the resident or guest and that the resident would supply her own supplies. Despite this, the facility did not ensure that dialysis supplies, including a functioning cycler, were available on specific days, and the resident missed PD treatments on those days.

The resident reported that she performed her own dialysis and that nursing staff did not monitor her during the dialysis process or check on her while it was occurring. She stated that earlier in the week she did not have the equipment needed to do her dialysis because the cycler she was using was broken and she was waiting for her family to bring supplies from home. She did not request supplies from the facility because her family usually brought enough supplies for about five days at a time. She acknowledged missing two or three days of dialysis in the past and stated that nurses took her vital signs, listened to her chest, and sent her for chest x-rays after she had missed days of dialysis, and that she later experienced vomiting and was sent to the hospital. CNA interview indicated that the family hooked the resident up to the dialysis machine and left the facility, and that if the family was late returning, the resident disconnected herself from the machine.

The DON stated that admission was contingent on the resident or family performing all aspects of PD independently and that facility nurses were responsible only for monitoring, which she described as reminding the resident to connect and disconnect from the machine. She reported that the facility did not have emergency PD equipment on site, that the resident missed two days of dialysis during a winter storm because the family did not bring supplies and the cycler was broken, and that the resident had stated she was fine with missing those treatments. The DON also stated that when a treatment was missed, the PCP was to be notified, and that the PCP was notified after missed treatments and the resident was assessed and sent for x-rays. RN staff reported they were not trained to connect, monitor, or disconnect the PD machine, and that their monitoring consisted of checking the catheter site for redness or drainage, taking vital signs, and confirming that the resident connected and disconnected herself, with the resident entering her own dialysis data into the machine. The facility’s PD inservice materials and an undated admission acknowledgment form showed that the facility did not provide staff-assisted PD, placed responsibility for supplies and equipment on the resident/family, and limited staff responsibilities to general clinical surveillance and vital signs, while prohibiting staff from performing PD connections or troubleshooting PD equipment. The resident was later admitted to the hospital with abdominal pain, nausea, vomiting, and suspected peritonitis, and the PCP stated that the resident not having supplies to properly do dialysis placed her at risk of becoming septic.