F0698

D

Failure to Follow Physician Order for Timely Removal of Dialysis Pressure Dressing

Monrovia, California Survey Completed on 03-03-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow a physician’s order for timely removal of a hemodialysis pressure dressing for a resident with end-stage renal disease who was dependent on renal dialysis and had severely impaired cognition and dependence for ADLs. The resident’s admission record documented ESRD and dialysis dependence, and the MDS showed severely impaired cognition and total dependence on staff. A physician order dated 2/22/26 directed that the resident’s dialysis pressure dressing on the right upper arm be removed four hours after return from dialysis. Nursing documentation showed the resident returned from dialysis on 2/24/26 at approximately 2:15 pm with the right upper arm fistula intact, without swelling or signs of infection.

The nursing progress note later that night, dated 2/24/26 at 10:50 pm, documented that the pressure dressing was removed and a new dressing applied. In interview, one LVN confirmed the resident returned from dialysis around 2:15 pm and that the fistula site was intact. Another LVN stated that on 2/24/26 they assessed the pressure dressing at about 4 pm after being informed the resident had returned from dialysis, found no leaking or signs of infection, and knew from the physician order that the pressure dressing should be removed four hours after return. This LVN stated they did not remove the pressure dressing until approximately 8 pm and then applied a new dressing due to scant bleeding at the fistula site, and documented the dressing change at 10:50 pm. The LVN also stated that leaving the pressure dressing on longer increased the risk of clotting. The facility’s ESRD policy stated that residents with ESRD would be cared for according to recognized standards of care and that staff would be trained in the care of grafts and fistulas.