Failure to Ensure Timely Dialysis and Complete Pre/Post-Dialysis Assessments
Summary
The facility failed to ensure that a resident who required hemodialysis consistently attended dialysis on time and received thorough pre- and post-dialysis assessments as ordered. The resident had renal insufficiency requiring dialysis, diabetes mellitus, paraplegia, and intact cognition, and was scheduled for dialysis on Monday, Wednesday, and Friday with a pick-up time of 9:30 AM. Review of the clinical record and MAR showed that required pre- and post-dialysis assessments were not fully completed on multiple dates, including missing documentation for thrill, bruit, access site condition, cognition, and weight, with no explanations in the record for these omissions. The facility’s hemodialysis policy required ongoing assessment and monitoring for complications before and after treatments, but the documentation did not reflect that these assessments were consistently performed. The resident reported being late to dialysis once or twice a week, stating she was supposed to be in the dialysis chair by 10:00 AM but often did not arrive until 10:30 AM, and that the dialysis center expected her to arrive by 9:30 AM to start on time. A dialysis provider staff member stated the resident had missed transportation to an appointment because she was not ready on time. The DON stated she expected residents with a 9:30 AM dialysis time to be up and ready by 8:00 AM and ready for pick-up by 8:45 AM, and that she did not know how many times this resident had been late. Staff interviews indicated that post-dialysis assessments should include vital signs, weight, and evaluation of the fistula site for thrill, bruit, appearance, and dressings, but the MAR review showed these elements were frequently incomplete, contributing to the identified deficiency in dialysis-related care and services.
Penalty
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The facility failed to consistently complete ordered pre- and post-dialysis assessments and related monitoring for three residents receiving hemodialysis. One resident with CHF, DM, HTN, and ESRD had repeated omissions of required pre- and post-dialysis vital signs and weights, and on many dialysis days no assessment was documented at all despite confirmation that dialysis occurred. Another resident with ESRD and significant functional impairment had multiple dialysis sessions where only blood pressure was recorded or where pre- or post-dialysis assessments were entirely missing, while progress notes and the MAR did not reflect these gaps. A third resident on hemodialysis with CKD stage 4 and DM lacked a documented post-dialysis assessment on one treatment day and had multiple days without the ordered daily weights. The regional RN confirmed these findings, which were inconsistent with the facility’s dialysis policy and the dialysis contract requiring comprehensive monitoring and assessment.
A resident with ESRD and multiple comorbidities receiving thrice-weekly hemodialysis at an outside center did not have consistent pre- and post-dialysis monitoring and communication, as required by physician orders. Review of the dialysis communication binder showed multiple treatment days with no forms documenting pre-treatment weights and VS or post-dialysis information. Several LPNs and the ADON acknowledged that forms were not consistently sent and documentation was missing from both the facility and the dialysis center, while the dialysis RN reported not receiving any information from the facility despite faxing post-dialysis reports back. The Regional Director of Operations confirmed the facility lacked a dialysis policy, contributing to the failure to ensure appropriate dialysis care and communication.
A resident with CKD stage five requiring peritoneal dialysis (PD) was admitted with pre-admission physician orders for three daily PD exchanges and monitoring for peritonitis (fever, abdominal pain, cloudy effluent), but these monitoring orders were not entered into the facility’s physician orders. The care plan referenced PD and general monitoring but did not specifically address peritonitis monitoring. Paper PD flowsheets showed incomplete and inconsistent documentation of exchanges and resident condition, including missing condition/comments for individual treatments and no record of one ordered PD exchange. The PD cycler flowsheet lacked effluent descriptions on multiple days. The PD nurse reported facility staff were expected to monitor effluent and symptoms, and the DON confirmed the absence of specific peritonitis monitoring orders, lack of an order for the PD cycler, and documentation gaps, despite a facility policy requiring ongoing assessment and monitoring for complications before, during, and after dialysis treatments.
Missing Dialysis Agreement and Inconsistent Dialysis Communication: A resident with ESRD, dementia, DM2, and hypertensive CKD received hemodialysis, but the facility had no prior agreement with the dialysis provider before the current annual survey. The care plan lacked communication interventions with the dialysis center, and review of dialysis records showed communication forms were present for only a few treatments. Staff described an unclear process, including uncertainty about a dialysis communication book and inconsistent exchange of paperwork between the facility and the dialysis center.
A resident with ESRD, diabetes, COPD, CHF, and dependence on renal dialysis received hemodialysis three times weekly at an off-site center, but the facility did not complete or document required pre- and post-dialysis assessments. The care plan and physician orders called for monitoring lung sounds, edema, AV fistula bruit and thrill, shunt site, and overall condition, yet the medical record contained no facility assessments around dialysis treatments. The only available pre-/post-treatment data (vital signs, weights, condition, and medications) came from the dialysis center’s communication forms. An LPN stated she filled out a form in a binder sent with the resident but could not produce the binder or a sample form, and the DON confirmed no facility-completed assessments could be located, despite a policy requiring assessment and monitoring for residents receiving dialysis.
The facility did not consistently complete or provide required information on dialysis handoff communication reports for multiple residents receiving dialysis, omitting vital signs, weights, code status, mental status, and other critical information. Nurse signatures were often missing, and there was a lack of documentation regarding access sites and catheter dressings after dialysis. Staff interviews confirmed that the expected processes for communication and assessment were not followed, and care plans lacked necessary interventions for monitoring dialysis-related complications.
Failure to Complete Ordered Pre- and Post-Dialysis Assessments and Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered and policy-required pre- and post-dialysis assessments and ongoing monitoring for multiple residents receiving hemodialysis. For one resident with CHF, type 2 DM, HTN, and ESRD admitted in late March, physician orders required dialysis three times weekly with pre-dialysis observations and vital signs at 4:30 A.M. and post-dialysis observations and vital signs at 12:30 P.M. Review of this resident’s record from January through April showed repeated omissions in the pre- and post-dialysis assessment forms, including missing weights, blood pressure, pulse, temperature, respirations, and pulse oximetry. On numerous dialysis days, there was no pre-dialysis assessment, no post-dialysis assessment, or both, despite dialysis communication forms from the dialysis center confirming that treatments were provided on those dates. A second resident, admitted with stroke, hemiplegia, hemiparesis, ESRD, muscle weakness, and reduced mobility, had a care plan for alteration in renal function related to ESRD and dialysis, with goals to avoid dialysis-related complications and interventions that included monitoring the access site, observing for fluid retention, obtaining vital signs as ordered, and coordinating care with the dialysis center. Physician orders required dialysis three times weekly with pre- and post-dialysis observations and vital signs on dialysis days. Review of dialysis communication sheets confirmed that this resident received multiple dialysis treatments over a six-week period. However, review of the corresponding pre- and post-dialysis assessments showed that on multiple dates, post-dialysis assessments were missing all vital signs except blood pressure, some pre-dialysis assessments were missing all vital signs except blood pressure, and on several dates either the pre- or post-dialysis assessment was not completed at all. Progress notes did not document any explanation such as resident refusal or incomplete assessments, and the MAR reflected that post-dialysis observations were documented as completed despite the missing data on the assessment forms. A third resident with CKD stage 4, DM, and hypothyroidism had a care plan for alteration in renal function indicating the resident was on hemodialysis. Physician orders required dialysis three times weekly, pre-dialysis observation and vital signs on dialysis days, post-dialysis observation on dialysis days, and daily weights. Review of the hemodialysis assessments showed that while pre- and post-dialysis assessments were completed on several treatment days, there was no evidence of a post-dialysis assessment for one dialysis date. Additionally, review of the medical record revealed that daily weights were not documented on multiple specified days, despite an active order for daily weights. In interviews, the regional RN confirmed the missing and incomplete dialysis assessments and missing daily weights, and acknowledged that dialysis assessments were not completed as ordered. The facility’s dialysis policy and dialysis contract required interdisciplinary monitoring, completion of pre- and post-dialysis assessments, and communication of information to the dialysis center, but the documented omissions showed these requirements were not consistently met for the residents reviewed.
Failure to Maintain Dialysis Communication and Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to provide safe and appropriate dialysis care by not consistently monitoring and communicating vital signs and weights before and after hemodialysis treatments for a resident dependent on dialysis. The resident, admitted with diagnoses including end stage renal disease, dependency on dialysis, type II diabetes mellitus with diabetic neuropathy, hemiplegia and hemiparesis following cerebral infarction, vascular dementia, and cognitive communication deficit, had physician orders for hemodialysis three times weekly at an outside dialysis facility, with instructions to send a communication form. Review of the dialysis communication binder for March 2026 showed missing pre- and post-dialysis communication forms, including pre-treatment weights and vital signs, on multiple treatment dates. Multiple LPNs and the ADON confirmed that dialysis communication forms were not consistently sent and that documentation was missing both from the facility and from the outside dialysis center for the identified dates. The dialysis RN at the outside facility reported they did not receive any documentation from the facility and stated it was important to know the resident’s condition prior to dialysis; the dialysis RN also reported that post-dialysis information was faxed to the facility daily. Additionally, review of physician orders for April 2025 included an order to send a communication form with the resident to dialysis, yet the Regional Director of Operations confirmed that the facility had no dialysis policy in place. These actions and omissions led to the cited deficiency for failure to monitor and maintain adequate communication with the outside dialysis center and to ensure the facility had a dialysis policy.
Failure to Implement PD Orders and Monitor Resident Receiving Peritoneal Dialysis
Penalty
Summary
The deficiency involves the facility’s failure to implement pre-admission physician orders for peritoneal dialysis (PD) and to provide ongoing monitoring for a resident with chronic kidney disease (CKD) stage five who required PD. Pre-admission orders dated 11/14/25 specified three daily PD exchanges at 6:00 A.M., 2:00 P.M., and 10:00 P.M., and directed staff to monitor for signs and symptoms of peritonitis, including fever, abdominal pain, and cloudy effluent. These monitoring orders were not entered into the facility’s physician orders. The resident’s care plan noted the need for PD and included general monitoring interventions (labs, signs of bleeding, bacteremia, septic shock, and significant vital sign changes), but did not specifically address the ordered monitoring for peritonitis. Review of PD documentation showed incomplete and inconsistent charting of treatments and resident condition. The paper peritoneal flowsheet had columns for time of PD and condition/comments, including instructions to call the nurse immediately for cloudy fluid, abdominal pain, or fever. However, the first entry on 11/15/26 at 2:00 P.M. only noted that the PD nurse completed the exchange, and the 10:00 P.M. entry that day had no condition/comment documentation. Subsequent days (11/16/25, 11/17/25, and 11/18/25) contained only one condition/comment entry per day rather than for each exchange, and there was no documentation that the 6:00 A.M. PD on 11/18/25 was completed. The PD cycler flowsheet starting 11/19/25 lacked any description of the effluent on multiple days. The PD nurse from the dialysis company stated facility staff were expected to monitor effluent for cloudiness and assess for abdominal pain and fever, and the DON confirmed there was no electronic physician order for peritonitis monitoring or for use of the PD cycler, that the paper charting did not allow for effluent description or symptom documentation for each treatment, and that PD was not documented at one ordered time. The facility’s dialysis policy required ongoing assessment and monitoring for complications before, during, and after treatments, which was not reflected in the documentation for this resident.
Missing Dialysis Agreement and Inconsistent Communication With Dialysis Center
Penalty
Summary
The facility failed to provide safe, appropriate dialysis care/services for a resident who required hemodialysis. Resident #12 was admitted with unspecified dementia with other behavioral disturbances, end stage renal disease, type 2 diabetes, and hypertensive chronic kidney disease. The care plan for end stage renal disease, revised 11/13/25, included assessment of the central line site every shift and dialysis on Tuesdays, Thursdays, and Saturdays, with the resident leaving the facility around 10:00 A.M. for an 11:00 A.M. chair time. However, there were no care plan interventions for communication with the dialysis center. Review of dialysis communication notes from 01/01/26 to 03/12/26 showed forms only for five dialysis treatments, with no communication forms for the remaining listed treatments during that period. Staff interviews showed confusion about the communication process and the absence of a consistent dialysis communication book. The DON stated the facility had a dialysis communication book but needed to locate it, and later verified that copies of past communication forms were not kept and that she had not called the dialysis center requesting daily communication forms. The RN supervisor stated the current process was to send a face sheet, blank progress note, medication list, and blank order form with the caregiver on dialysis days, and the Administrator stated that prior to the effective date of 03/12/26 on the dialysis agreement, there was no previous agreement between the facility and the dialysis provider used by the resident.
Failure to Perform and Document Pre- and Post-Dialysis Assessments
Penalty
Summary
The facility failed to ensure a resident who required dialysis received ongoing assessments of condition before and after dialysis treatments, as required by facility policy and physician orders. The resident had been admitted with multiple diagnoses including end stage renal disease, diabetes mellitus, dependence on renal dialysis, morbid obesity, COPD, and CHF, and received dialysis three times per week at an off-site location. The care plan noted the resident frequently refused dialysis and included interventions such as monitoring lung sounds, edema, shunt site, bruit and thrill, and maintaining communication with the dialysis center. Physician orders included checking the left arm AV fistula for bruit and thrill every shift and documented the scheduled dialysis days and times. Medical record review revealed no evidence that the facility completed pre-treatment or post-treatment assessments related to the resident’s dialysis sessions. Although the dialysis center’s communication forms from several months documented pre- and post-treatment weights, vital signs, condition, and medications administered, these were completed by the dialysis center, not the facility. An LPN reported that the resident had a binder taken to dialysis and that she filled out a form with vital signs and any signs or symptoms of pain or sickness, but she could not produce the binder or a sample of the form. The DON confirmed she was unable to locate any pre- or post-dialysis assessments completed by facility staff and verified that the available communication forms were from the dialysis center, not the facility, despite the facility’s Dialysis Management policy requiring assessment and monitoring for complications.
Failure to Maintain Communication and Documentation for Dialysis Care
Penalty
Summary
The facility failed to maintain adequate communication and collaboration with the dialysis clinic regarding the care and services for multiple residents requiring dialysis. Specifically, the facility did not consistently complete or provide required information on the Dialysis Hand Off Communication Reports for several residents, including vital signs, weights, code status, mental status, vaccination status, allergies, diet and fluid restrictions, compliance with diet and fluids, new medications, medical problems, lab draws, and signs or symptoms of infection. Additionally, nurse signatures were frequently missing from both pre- and post-dialysis sections of the communication forms, and there was a lack of documentation regarding the condition of access sites and catheter dressings upon residents' return from dialysis. Several residents with complex medical histories, such as end stage renal disease, chronic respiratory failure, dependence on ventilators, and feeding tubes, were affected by these deficiencies. For example, one resident with severe cognitive impairment and multiple comorbidities had repeated omissions in the reporting of vital signs, infection status, and nurse signatures before and after dialysis sessions. Other residents, including those with moderate cognitive impairment or intact cognition, also experienced similar lapses in documentation and communication, with entire sections of the required forms left blank and no evidence of pre- or post-dialysis assessments being completed. Interviews with facility staff, including LPNs and the DON, confirmed that the expected process for completing and reviewing dialysis communication reports was not being followed. The facility's own policies and the dialysis coordination agreement required written communication of changes in resident condition and compliance with medical management, but these were not adhered to. Furthermore, care plans for residents receiving dialysis often lacked interventions related to monitoring for changes in mental status, infection, or fluid status, and there were no physician orders for pre- and post-dialysis assessments for the affected residents.
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