A resident with heart failure, CKD, and cirrhosis who received hemodialysis three times weekly missed one or more scheduled dialysis sessions when a malfunctioning elevator prevented timely transport, with staff and the resident confirming that elevator breakdowns had caused missed appointments and led to the resident’s relocation to a lower floor. Review of the hemodialysis communication book over several weeks showed that on most documented dialysis days, either the pre- or post-dialysis nursing assessment was missing, and there was no corresponding documentation in the EMR, despite facility policy requiring complete pre- and post-treatment assessments for dialysis care.
Two residents receiving hemodialysis had missing pre- and post-dialysis documentation and inconsistent oversight of their access sites. The facility’s LPNs reported completing pre-dialysis forms and post-dialysis checks, but records showed many absent communication sheets and no routine documented assessment of the Tesio catheter or fistula site. One resident also reported returning from dialysis with a clotted catheter and not being assessed or having VS taken.
A resident with ESRD received hemodialysis at an outside dialysis center, but the facility did not document ongoing pre- and post-dialysis assessments, including access site checks, or consistently review dialysis communication reports. The resident’s care plan addressed the dialysis port, and staff said pre-dialysis vitals, access site monitoring, and review of return information were part of the process, but multiple dialysis treatments lacked documented assessments and several communication forms were missing from the record.
A resident with ESRD and dependence on HD did not receive consistent pre- and post-dialysis oversight. Communication sheets sent with the resident were often incomplete or missing, with absent VS, weights, and staff signatures, and staff gave conflicting accounts about who was responsible for assessments. An RN did not complete the post-dialysis assessment or check the fistula when the resident returned after shift change, and the DON stated these assessments were often missed.
Failure to monitor and document dialysis care: A resident with CKD and ESRD received hemodialysis at an outside center three times weekly, but the facility had no documented dialysis policy, no specific care plan interventions, and no physician orders for post-dialysis assessment or access-site monitoring. Repeated dialysis trips were documented, yet there was no evidence of pre- or post-dialysis evaluations. The resident said staff did not manage the access site, and the DON could not explain the dialysis treatment, access type, or need for a physician order.
A resident with kidney failure who received hemodialysis had no documented ongoing pre- and post-dialysis assessment, access-site monitoring, or consistent communication between the facility and the dialysis center. The care plan and orders called for monitoring and notification parameters, but staff did not document routine vital signs, and an LPN said the facility usually assumed dialysis went smoothly if no report was received.
Dialysis Communication and Oversight Not Maintained: A resident with ESRD received hemodialysis at an outside center, but the facility did not consistently complete or review the dialysis communication binder, did not maintain ongoing communication with the dialysis center, and was unaware the resident was on a 1000 mL/day fluid restriction. The resident reported staff did not reliably obtain pre-dialysis vital signs or collect the binder after treatment, and the dialysis RN confirmed the facility stopped providing the communication form and did not relay additional information.
A resident with ESRD, DM, and dependence on renal dialysis received hemodialysis at an outside center, but the facility had no documented physician order for dialysis, pre/post dialysis assessments, or vascular access monitoring. The resident had a right chest Permacath, yet staff could not confirm consistent documentation of site checks, and the handoff record lacked some pre- and post-dialysis evaluations.
A resident with ESRD and cognitive impairment did not receive dialysis access care consistent with the physician order and facility policy. Staff were expected to remove the AV shunt dressing 24 hours after dialysis, but the resident reported removing it upon return from dialysis, and the shunt was observed reddened and moist. Nurses said they had been educating the resident to keep the dressing on, but there was no documentation of the behavior, no documented education, and no evidence the MD was notified.
A resident receiving hemodialysis had no documented ongoing pre- and post-dialysis assessments or consistent access-site checks, and the facility did not reliably review or complete the dialysis communication book or contact the dialysis center when needed. The resident also reported that lunch was often not sent on dialysis days, and staff observations showed the meal and communication binder were sometimes not prepared until the resident asked for them.
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