F0698

E

Failure to Monitor and Assess Dialysis Residents and Educate Nursing Staff

Saint Paul, Minnesota Survey Completed on 03-24-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide dialysis care and monitoring consistent with professional standards for multiple residents receiving hemodialysis at an outside provider. Three residents with end stage renal disease or dependence on renal dialysis (R1, R5, and R7) had physician orders and care plans indicating the need for ongoing dialysis and specific monitoring for complications such as bleeding, hemorrhage, bacteremia, septic shock, renal insufficiency, infection at the access site, and peripheral edema. Despite these documented needs and interventions, the treatment administration records (TARs) for these residents did not include dialysis-related ongoing monitoring before and after dialysis treatments, and the facility’s Clinical Monitoring–Dialysis UDA assessments were not completed on multiple dialysis days listed in the report.

For R1, hospital records documented end stage renal disease on dialysis with a left arm AV fistula and a schedule of hemodialysis three times per week. The care plan included detailed nursing interventions to monitor and document for dialysis-related complications and to encourage attendance at scheduled dialysis appointments. However, the TAR for the period reviewed did not identify dialysis monitoring for complications, and progress notes only briefly noted that the resident was out to dialysis, without additional assessment data. The record also did not show completion of the Clinical Monitoring–Dialysis UDA on the specified dialysis date.

For R5, progress notes repeatedly documented a diagnosis of dependence on renal dialysis and referenced ongoing dialysis three times per week, including multiple entries noting the resident’s return from dialysis with statements such as “no new orders,” “vital signs normal,” “denied shortness of breath,” and “no signs or symptoms of discomfort.” The care plan again listed specific monitoring interventions for edema, bleeding, infection, and renal insufficiency, and the MDS documented dependence on renal dialysis. Nonetheless, the TAR for the reviewed month did not include dialysis monitoring for complications, and the Clinical Monitoring–Dialysis UDA was not completed on numerous dialysis dates identified in the report.

For R7, progress notes documented dependence on renal dialysis and multiple instances of the resident being at dialysis or returning from dialysis, with limited narrative such as noting attendance at dialysis or that there were no new orders and no complaints of pain. The care plan required monitoring and documentation for peripheral edema, bleeding, bacteremia, septic shock, renal insufficiency, infection at the access site, and depression, and the MDS recorded chronic kidney disease and dependence on renal dialysis. Despite these documented needs, the TAR did not show dialysis-related ongoing monitoring, and the Clinical Monitoring–Dialysis UDA was not completed on multiple dialysis dates. The resident reported that nurses did not check the access site before and after dialysis and did not complete an assessment upon return from dialysis.

The deficiency also includes a systemic failure to ensure that licensed nurses had appropriate education to care for and assess residents receiving dialysis. Personnel records for 26 of 34 licensed nurses lacked onboarding orientation checklists identifying dialysis education. In interviews, several RNs stated they had not received training on dialysis residents or that their understanding of complications was limited to bleeding at the access site or changes in vital signs. One RN reported that after a resident returns from dialysis, she only takes vital signs and does not complete any other assessment, and another RN acknowledged that if a dialysis assessment is not present in the chart, it means it was not completed. The clinical learning and development specialist and the administrator confirmed that dialysis-specific education was not provided at the corporate level and that training, if any, was left to individual facilities, while also stating that the expectation was for nurses to complete a dialysis assessment in the chart after treatment. The absence of documented dialysis assessments and the lack of structured dialysis education for most licensed nurses contributed directly to the failure to provide dialysis services consistent with professional standards of practice.