A resident with ESRD and diabetes received dialysis, but staff failed to monitor the dialysis access correctly after the resident’s access changed from a CVC in the right chest to an AV fistula in the left upper arm. Nursing staff documented checks for bleeding and post-dialysis status, but were not aware of the fistula, did not assess for bruit and thrill, and did not have direction to avoid BP checks on the access arm. The DON stated staff should know the correct access site and assess it based on the type and location of access.
Failure to monitor dialysis site after treatment: A resident with ESRD and anemia in CKD returned from dialysis and was observed eating before staff checked the fistula site. An RN obtained vital signs but did not inspect the fistula for bleeding, bruit, or thrill as ordered. The resident’s orders and care plan required post-dialysis vitals and ongoing fistula/site monitoring, and the dialysis CM and DON stated the site should be checked right after the resident returns from dialysis.
Dialysis Access Monitoring Not Properly Performed: A resident with ESRD and a need for HD had orders and a care plan directing staff to check the left arm AV fistula for thrill and bruit every shift. After the resident returned from dialysis, an LPN checked vitals and the dressing but did not auscultate the access site, and later stated they did not know what a thrill or bruit was until they looked it up. The DON stated staff were expected to check the site for bleeding, thrill, and bruit after dialysis.
Failure to Clarify and Document Dialysis Fluid Restriction: A resident receiving dialysis with ESRD and other chronic conditions was identified as at risk for fluid overload, but the care plan did not specify a daily fluid allowance or direct staff to monitor intake. The EHR lacked a physician order or dialysis recommendation for fluid restriction, and there was no documentation that the facility clarified the restriction with the dialysis provider. Staff gave conflicting reports about whether a fluid restriction existed, while observations showed multiple water containers in the resident’s room and the resident stated he did not know how much fluid he was allowed.
Incomplete and inaccurate dialysis assessments: A resident receiving hemodialysis had missing and incorrect pre- and post-dialysis documentation, including absent current weights, vital signs, and access-site assessments. The care plan lacked dialysis-specific interventions, one dialysis day had no communication form, and staff documented findings such as "ports capped and clamped" and no bruit, which the RN, MD, and DON stated were not accurate for the resident’s access and did not reflect proper dialysis monitoring.
The facility failed to provide appropriate dialysis care for two residents. One resident with ESRD, cardiac conditions, anemia, and anticoagulant use had no consistent communication between the facility and dialysis center, missed vital sign checks before metoprolol with hold parameters, had water and soda despite a fluid restriction, lacked EBP, and had repeated bleeding from a dialysis access site with no documented physician orders for CVC dressing care or AV fistula monitoring. A second resident on dialysis also had a fluid restriction and care plan needs, but the record lacked evidence of ongoing communication with the dialysis center and showed a water pitcher in the room despite the restriction.
A resident with ESRD receiving hemodialysis had an inaccurate dialysis care plan and inconsistent dialysis documentation. The care plan lacked the dialysis clinic’s contact info, the resident’s actual CVC access type, and clear coordination details, while orders incorrectly referenced a fistula/AV graft and staff documented thrill/bruit checks and dressing removal for a non-existent access type. The chart also lacked complete dialysis summaries, and staff and leadership acknowledged they were not consistently receiving or requesting dialysis paperwork or other key information from the dialysis clinic.
A resident who received scheduled dialysis had intact cognition and diagnoses including dependence on renal dialysis, CKD stage 5, and vascular access implants/grafts. The facility did not consistently send required dialysis communication forms and transfer information with the resident, with missing or incomplete details such as vital signs, current meds, recent condition changes, weights, and/or MD orders; the resident stated no paperwork was sent, and the DON confirmed the forms were expected but not consistently provided.
The facility failed to provide dialysis care consistent with professional standards by not performing or documenting required pre- and post-dialysis assessments for several residents with ESRD or dependence on renal dialysis. Although care plans and orders called for monitoring of vital signs, access sites, edema, and signs of bleeding, infection, and renal insufficiency, the TARs lacked dialysis-specific monitoring, and the facility’s Clinical Monitoring–Dialysis assessments were not completed on multiple dialysis days. One resident reported that nurses did not check the access site or perform assessments before or after dialysis. Additionally, personnel files for most licensed nurses did not show dialysis-related orientation, and multiple RNs stated they had little or no training on dialysis residents and limited their checks mainly to vital signs, despite an expectation that a full dialysis assessment be completed after each treatment.
Incomplete Dialysis Assessment Monitoring: A resident with ESRD-related diagnoses, HF, DM2, oxygen dependence, and chronic respiratory failure had ordered pre- and post-dialysis assessments, but the facility documented them only on a few dialysis days. The DON confirmed the forms were not sent consistently, RN-B could not produce the assessment sent with the resident, and the MD stated the facility was expected to complete the assessments and notify the dialysis center of any changes in weight and status.
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