Missed Hemodialysis Treatments and Lack of Monitoring for ESRD Resident
Summary
The deficiency involves the facility’s failure to ensure that a resident with ESRD received ordered hemodialysis (HD) treatments and that her dialysis-related care plan was implemented. The resident was admitted with diagnoses including joint replacement surgery and ESRD requiring HD, with physician orders for HD on Monday, Wednesday, and Friday at a specified time, and transportation arranged for pickup prior to each treatment. Her care plan, initiated shortly after admission, identified a need for dialysis with goals of avoiding complications related to fluid overload and maintaining normal weight, and included interventions to provide HD on the ordered schedule and to monitor for changes in level of consciousness, vital signs, heart and lung sounds, and edema, with reporting to the primary physician as needed. Record review showed no documentation that the resident received HD on two ordered treatment days and no documentation that licensed nurses identified, monitored, or assessed her for complications related to the missed HD treatments on those days. The resident’s emergency contact reported that the resident missed an HD treatment because transportation did not pick her up, and that an additional treatment scheduled for the following day was also missed due to the same transportation issue. The emergency contact expressed concern that the resident would retain excess fluids because her kidneys were no longer functioning. Multiple staff interviews confirmed breakdowns in both transportation coordination and nursing follow-through. The RN Supervisor acknowledged that on the morning shift when the resident reported missing HD due to lack of transportation, she did not assess or monitor the resident for a change in condition, did not notify the primary physician, and did not initiate monitoring for potential complications. The Case Manager stated she had confirmed transportation and arranged an extra HD treatment, documented it on the communication board, and informed the RN Supervisor, while another RN reported endorsing the extra HD appointment to the next shift. However, the RN working the following morning shift stated she did not receive endorsement or see any communication board note about the appointment. Staff also confirmed that despite the resident missing two HD appointments, there was no monitoring initiated, no specific plan of care formulated for the missed HD, and no notification of the primary physician. When the resident presented to the dialysis center at the next scheduled treatment, the dialysis clinical coordinator assessed her with facial and generalized body edema and documented that she was 11 kg above her prescribed target weight. Policy review showed that the facility’s transportation policy required assistance with arranging transportation as needed, the ESRD policy required that residents with ESRD be cared for according to recognized standards and that licensed nursing staff be trained to recognize signs and symptoms of worsening condition or complications, and the change-in-condition policy required prompt physician notification and detailed documentation, including at least 72 hours of monitoring, vital signs each shift, evident care plan, and reassessment when a change in condition occurred. These policy requirements were not followed in relation to the missed HD treatments and lack of monitoring and assessment for this resident.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Incomplete Dialysis Communication Records: The facility failed to maintain ongoing communication and collaboration with the dialysis provider for two residents receiving HD. For one resident with ESRD and hemiplegia, and another resident with CKD and rib fractures, dialysis communication forms were left incomplete and unsigned on multiple occasions, including sections for pre-transfer and post-return information. An HD RN reported difficulty reaching the facility and said the communication book had not been filled out for a long time, while the DON confirmed the nurses were not completing the dialysis communication forms even though vital signs were available.
Dialysis Access Monitoring and Order Documentation Deficiencies: The facility failed to document daily access site assessments for a resident receiving HD, with records showing checks on dialysis days but not on non-dialysis days. The facility also lacked a complete physician order for another resident’s dialysis schedule, clinic location, and chair time, even though staff confirmed the resident went to dialysis on M/W/F and the care plan was not updated to match the current schedule.
The facility failed to have an active agreement with the dialysis center for two residents who were dependent on dialysis. One resident had diabetes, a leg amputation, and ESRD, and the other had diabetes and renal dialysis dependence. The Administrator stated the facility did not have a contract with the dialysis center and was waiting to receive one.
A resident with ESRD, DM, and malnutrition did not have dialysis communication forms completed with snack or food before transport, chair time, or post-dialysis assessment details. Meal intake, refusals, and substitutions were not consistently documented, and staff and family reported the resident often missed meals, did not receive alternatives, and had a hypoglycemic episode after insulin when he refused a meal tray.
A resident with ESRD and dependence on renal dialysis had orders and a care plan for dialysis three times weekly, but the facility could not retrieve dialysis communication forms and the binder was empty. An LPN said the forms were used to share pre- and post-dialysis vital signs and new orders, while the DON stated the dialysis center changed the resident’s schedule to two treatments per week without notifying the facility. A handwritten note and dialysis attendance record showed the resident was scheduled for two weekly treatments and often missed appointments.
Missed Dialysis Access Assessments: A resident receiving HD for ESRD with a LUE AV fistula did not consistently receive required fistula and post-dialysis assessments. The care plan and EMR directed staff to complete dialysis evaluations before dialysis, after dialysis, and on non-dialysis days, but records showed signed-off assessments with missing data on non-dialysis days and a missed post-treatment check on a dialysis day. The resident reported that staff often checked VS before dialysis but not afterward or on days without dialysis, and the DON acknowledged that post-dialysis checks did not always occur.
Incomplete Dialysis Communication Records
Penalty
Summary
The facility failed to ensure ongoing communication and collaboration with the dialysis provider for two residents who required dialysis services. One resident was admitted with hemiplegia affecting the left nondominant side and end stage renal disease, with an order for hemodialysis on Tuesday, Thursday, and Saturday. The resident’s hemodialysis communication records for multiple dates showed sections that were not completed and not signed by the nurse, including sections to be completed before transfer and upon return from dialysis. During interview, staff stated the facility communicated with dialysis nurses through a communication book, but the dialysis RN reported difficulty communicating with the facility and stated that the communication book had not been filled out for a long time. A second resident was admitted with multiple rib fractures and chronic kidney disease stage 3, with orders for dialysis on Monday, Wednesday, and Friday and for communication with the dialysis center regarding labs and plan of care. The resident’s dialysis communication records for two dates showed the section to be completed by the facility upon return from dialysis was not completed and not signed by the nurse. The facility policy stated that agreements with the contracted ESRD facility include how information will be exchanged between facilities, but the records and interviews showed that the required dialysis communication documentation was not consistently completed.
Dialysis Access Monitoring and Order Documentation Deficiencies
Penalty
Summary
The facility failed to ensure that a resident receiving hemodialysis had the dialysis access site assessed within the standards of practice. The resident had diagnoses of dependence on dialysis and diabetes mellitus, and the record showed intact cognition with a BIMS score of 15. The care plan directed staff to complete a dialysis flow sheet daily, observe the shunt access site for complications, report abnormalities to the physician, and avoid blood pressure checks and needle sticks in the right arm. Although dialysis communication sheets showed access site assessments on dialysis days, the resident’s EMR lacked evidence that staff monitored and assessed the access site on non-dialysis days. During observation on 06/03/26, the resident was seen in the dining room before leaving for dialysis. A licensed nurse stated that nursing staff obtained vital signs and weights pre- and post-dialysis and that the resident attended dialysis every day except Thursday, Saturday, and Sunday. The nurse also stated staff checked the access site on the days the resident went out for dialysis and could not find documentation of access site checks on Thursday, Saturday, and Sunday. An administrative nurse later stated the access site should be accessed and documented daily on the MAR or TAR. The facility also failed to ensure that another resident had an active physician’s order that included the dialysis clinic, location, chair time, and days of treatment. That resident had diagnoses of CKD stage 4 and type 2 diabetes mellitus, with records showing hemodialysis during the observation period and a BIMS score of 15 on one assessment and 7 on another. The care plan listed dialysis days and chair time, but it had not been updated to reflect the resident’s current Monday, Wednesday, and Friday schedule at 05:15 AM or the current transportation provider. The EMR contained orders for access monitoring, pressure dressing removal, and pre- and post-dialysis assessments, but it lacked a physician’s order specifying the dialysis clinic, clinic location, chair time, or days of dialysis. Staff interviews confirmed the resident went to dialysis on Monday, Wednesday, and Friday and that the physician’s order should include when, where, and what days dialysis occurred.
Missing Dialysis Center Contract for Two Residents
Penalty
Summary
The facility failed to have an active agreement and contract with the dialysis center for two residents who required dialysis services. Resident 103 was admitted with diagnoses including diabetes, leg amputation, and end stage renal disease, and was dependent on dialysis. Resident 2 was admitted with diagnoses including diabetes and was also dependent on renal dialysis. Both residents were able to communicate their needs. Review of facility contracts showed no active agreement with the dialysis center where these two residents were receiving dialysis, and the Administrator stated the facility did not have an agreement or contract with the dialysis center and was waiting to receive one.
Dialysis Nutrition and Communication Documentation Not Completed
Penalty
Summary
The facility failed to ensure safe, appropriate dialysis care and services for a resident with ESRD, dialysis dependence, moderate protein-calorie malnutrition, and type 2 DM with hyperglycemia. The resident’s care plan identified dialysis needs and also identified unplanned weight loss and risk for malnutrition, with interventions to monitor and record food intake at each meal and provide supplements as ordered. The resident’s active orders included Nepro three times daily for weight loss and decreased appetite, as well as a renal-liberalized diet with a high-protein snack between meals. Record review of the dialysis communication forms showed that on multiple dialysis days the resident was sent to dialysis without a snack or food. The forms also did not document the day and/or chair time for treatment on several dates, and they did not show completion of assessment and observation after dialysis on some dates. Progress notes from the same period did not document daily food intake for each meal, refusals, or substitutions. The record also did not show that the resident was sent to dialysis with a high-calorie snack or received a meal prior to dialysis when a scheduled time at the facility was missed. The resident and family reported that the resident often did not eat facility meals, that family brought food for him, and that staff did not offer another meal or snack when he did not like the food. The resident reported refusing meals because food was cold and said staff did not warm it or offer anything else. A progress note documented that the resident had a hypoglycemic episode after receiving scheduled insulin and then refusing the meal tray; the note also stated he did not eat a snack or lunch tray and received a meal replacement shake after the episode occurred. Staff interviews confirmed expectations that dialysis residents should receive food or a snack before dialysis and that meal refusals should be addressed with an alternative, but the DON stated the facility did not have a dialysis policy because it did not provide the treatment.
Missing Dialysis Communication and Unnotified Schedule Change
Penalty
Summary
The facility failed to maintain ongoing communication for a resident receiving dialysis services. Resident B had diagnoses including end stage renal disease and dependence on renal dialysis, was cognitively intact, and had a care plan and physician orders for dialysis three times per week on Monday, Wednesday, and Friday. The resident’s record contained no dialysis communication forms after 3/20/26, and the dialysis communication binder behind the nurse’s station was empty when reviewed. LPN 3 stated the dialysis communication forms were used to communicate pre- and post-dialysis vital signs and any new orders or instructions from the dialysis center. During interview, the Facility Administrator stated the binder had been emptied after the resident died and that the transportation service may have had the communication sheets. The DON stated the dialysis center changed the resident’s dialysis order from three days per week to two days per week without notifying the facility. A handwritten note with dialysis appointment dates indicated the resident had been scheduled two days per week and often missed dialysis appointments. The facility later provided a dialysis contract stating the center would maintain reports of services rendered and the facility could photocopy those reports, along with a treatment attendance record showing dialysis treatments were prescribed two times per week on Monday and Friday.
Missed Dialysis Access Assessments
Penalty
Summary
The facility failed to ensure post-dialysis assessments and fistula assessments were consistently completed for a resident who received hemodialysis for end stage renal disease and had an AV fistula in the left upper extremity. The resident’s care plan directed staff to listen to and feel the dialysis site before dialysis, after dialysis, and on non-dialysis days, and the electronic record also directed completion of a dialysis evaluation before dialysis, after dialysis, and on non-dialysis days. The resident had intact cognition and reported that nurses often checked vital signs before dialysis but frequently did not check her afterward or on days without dialysis, and she stated that no one had checked her access site the previous day. Record review showed that on two non-dialysis days, staff signed off that the dialysis assessment was completed even though the actual evaluation data was missing. On a dialysis day, the facility failed to perform the required check after the resident returned from treatment. Staff confirmed that dialysis residents were expected to be evaluated every day, including assessment of the fistula for thrill and bruit and vital signs before and after dialysis appointments. The DON acknowledged that post-dialysis checks did not always happen and stated that daily checks on non-dialysis days only occurred if specifically ordered, with missed checks to be documented as refused or if the resident was out of the building.
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