Failure to Document Post-Dialysis Vitals and Access Site Assessments
Penalty
Summary
The facility failed to provide complete and documented dialysis-related monitoring for a resident receiving renal dialysis. The resident had diagnoses including heart failure, end stage renal disease, diabetes, bilateral lower extremity impairment, and was dependent on dialysis. An MDS assessment indicated the resident was cognitively intact for daily decision making. The care plan, initiated in June and revised in February, identified the need for dialysis related to renal failure and included interventions to assess the dialysis access site for redness, swelling, pain, or drainage, and to encourage attendance at scheduled dialysis appointments. A physician’s order dated December 19 directed staff to record vital signs pre- and post-dialysis, and another order dated March 2 directed staff to assess the dialysis access site for redness, swelling, pain, and drainage. Record review showed that there was no physician’s order to assess the dialysis access site until March 2, despite the care plan intervention to do so. The MARs for January and February lacked documentation of dialysis access site assessments. The January MAR showed post-dialysis vital signs coded with a “9” (indicating to see progress notes), but there were no corresponding progress notes for multiple dialysis dates in January. Additionally, the February MAR lacked any documented post-dialysis vital signs on one dialysis date. The facility’s Dialysis Monitoring and Communication Policy required observation of the dialysis access site for increased redness, swelling, bleeding, pain, and drainage, and documentation of abnormal findings in the medical record. During interview, the Nurse Consultant acknowledged the absence of post-dialysis vital signs on the identified February date and understood the concern regarding missing January post-dialysis progress notes and lack of access site assessments.
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