A resident with ESRD receiving hemodialysis had repeated gaps in the dialysis communication binder, including missing pre- and post-dialysis documentation and several instances where the dialysis center did not return completed information. Interviews with the LPN/UM and DON showed inconsistent understanding of who completed each section of the communication form, while the facility policy required routine communication sheets to be sent to and received from the dialysis unit.
A resident receiving dialysis had conflicting orders for lactulose, including a standing no-lactulose order for dialysis residents and a PRN lactulose order for constipation. The MAR showed lactulose was administered, and the LPN, DON, physician, and RNC all acknowledged the conflicting orders and that the no-lactulose order should not have remained in place.
A resident receiving dialysis had a physician-ordered 1500 mL fluid restriction, but multiple beverages were observed at the bedside and the resident was unsure about the restriction. Staff gave inconsistent accounts of how fluid intake should be monitored and documented, and no fluid intake documentation was found in the communication book or progress notes despite facility policy requiring nursing to document the amount of fluids the resident receives.
Failure to Complete Post-Dialysis Assessments: A resident with dependence on renal dialysis, hypertension, and severe cognitive impairment received hemodialysis on a regular schedule, but the facility did not complete the required post-dialysis return assessments or document vital signs and access-site checks on multiple occasions. Review of the dialysis communication records and EMR showed missing nurse assessments after return from the dialysis center, and an LPN and the DON confirmed the post-dialysis assessment requirements.
A resident with ESRD, HTN, and severe cognitive impairment received carvedilol on dialysis days at an 8:00 AM med pass despite a 6:00 AM dialysis chair time and return to the facility around late morning. The DON confirmed the resident could not receive 8:00 AM meds while out for dialysis and stated med times should be adjusted to accommodate dialysis, but the eMAR still showed the dialysis-day carvedilol documented as given at the regular 8:00 AM time. The CP’s med regimen reviews noted no concerns, and the RCP stated the dialysis conflict should have been reviewed.
A resident with ESRD, dialysis dependence, and type 2 DM had ordered HD on M/W/F at 7:15 AM, plus insulin lispro, sevelamer, and timolol. The care plan did not address coordinating meds with dialysis, and MAR review showed multiple doses documented as not administered during dialysis times. Staff stated dialysis residents’ meds should be scheduled before or after dialysis, and the DON said the meds should be sequenced to when the resident was in the facility with MD approval.
Missing Dialysis Progress Notes: The facility failed to consistently document required pre- and post-HD Progress Notes for two residents receiving HD. Both residents had renal dialysis dependence and anemia in CKD, with physician orders and MAR sign-offs indicating dialysis documentation should be completed, but the EMR lacked multiple notes for outgoing and return dialysis care. An RN and an LPN/UM stated that pre- and post-HD VS, access checks, bleeding assessment, and any concerns should be documented in the EMR.
A resident with ESRD on hemodialysis had a dialysis communication form that included an order to stop Calcium Acetate based on lab results, but staff did not transcribe the order or notify the MD, and the medication continued to be given. The resident also had a right chest wall permcath, but the care plan incorrectly addressed bruit and thrill instead of the ordered access-site checks for infection, drainage, bruising, and bleeding.
A resident with ESRD and moderate cognitive impairment received dialysis on a Tue/Thu/Sat schedule, but ordered meds were not administered on multiple dialysis days because the resident was out to dialysis, and staff acknowledged the timing should have been adjusted. The resident also had a 1000 mL fluid restriction order that was exceeded on several days, with the DON stating the resident was noncompliant and no documented physician clarification found during review.
A resident with ESRD on HD had a physician-ordered 1000 mL FR split between nursing and dietary, but meal tickets and room observations showed beverages provided without the FR being reflected on the meal ticket or meal pattern. The resident’s dietary fluids totaled more than the ordered allowance, and staff interviews showed the FSD did not see the resident flagged for FR in the computer while the RD confirmed the printed meal tickets exceeded the ordered dietary amount.
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