145632
04/04/2025
Warren Barr South Loop
1725 South Wabash Chicago, IL 60616
F 0698
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Level of Harm - Minimal harm or potential for actual harm
Based on interview and record review, the facility failed to ensure hemodialysis services were provided 3 times weekly as ordered by physician to a resident (R5). This failure has the potential to affect 1 (R5) of 3 residents reviewed for Quality of Care /Treatment.
Residents Affected - Few The findings include: R5's admission record showed admit date on 02/18/2025 with diagnoses not limited to End stage renal disease, Dependence on renal dialysis, Arthritis due to other bacteria right knee, Acute and chronic respiratory failure with hypoxia, Gout, Benign prostatic hyperplasia, Type 2 diabetes mellitus, Chronic diastolic (congestive) heart failure, Unilateral primary osteoarthritis right knee, Essential (primary) hypertension. R5 was discharged to facility on 3/10/25. R5's order summary report dated 4/1/25 showed order not limited to: Hemodialysis MWF (Monday, Wednesday, Friday). On 4/1/25 at 2:22 PM V17 (LPN / Licensed Practical Nurse) stated she has been working in the facility for 2 years and is regularly assigned on the 1st floor. She said she had worked with R5 who was receiving HD (hemodialysis) 3x per week MWF (Monday, Wednesday, and Friday) as ordered by physician. She stated every dialysis day, dialysis assessment is printed out, given to resident including Face sheet and POS (Physician Order Sheet). V17 said dialysis resident would come back to facility with paperwork (dialysis assessment) filled out by dialysis center as a form of dialysis communication. V17 said if resident missed dialysis treatment, physician should be informed and documented. V17 stated R5 was scheduled for hemodialysis on 2/28/25 (Friday) but due to transportation issue, hemodialysis was rescheduled on 3/1/25. Reviewed R5's EHR (electronic health record) with V17 and was unable to find documentation that physician was informed regarding missed dialysis on 2/28/25. She said she does not know if R5 received dialysis on 3/1/25, no documentation found. V17 said she is always off every Monday and does not know if R5 received hemodialysis on 3/3/25. On 4/2/25 At 1:34PM V13 (Registered Nurse / RN) stated resident on hemodialysis is sent out to dialysis center to receive hemodialysis as ordered by physician. She said Dialysis assessment should be completed every dialysis day as a form of dialysis communication. V13 said usually she would do progress notes if resident is going out and had received hemodialysis. She said if resident missed or refused hemodialysis, inform physician. Surveyor reviewed R5's EHR with V13 and she confirmed that she worked with R5 on 3/3/25 (Monday), dialysis day. She said she is not sure if R5 received hemodialysis that day. V13 unable to find documentation if R5 received hemodialysis on 3/3/25. No dialysis assessment, no progress notes or documentation found in R5's EHR (electronic health record) on 3/3/25 that R5 received hemodialysis as ordered by physician.
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145632
145632
04/04/2025
Warren Barr South Loop
1725 South Wabash Chicago, IL 60616
F 0698
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Few
On 4/2/25 At 1:54pm V2 (Director of Nursing / DON) stated hemodialysis, should have a physician order in resident's record and should be followed. She said when a resident going out for HD (hemodialysis), Dialysis assessment is printed out by nurses and sent with resident together with Face sheet and POS (physician order sheet) and should be documented in progress/resident's record that resident received HD. V2 said dialysis assessment is a form of communication between facility and dialysis center. She said if resident refused or missed dialysis treatment, physician should be informed and documented. V2 said HD is very important to be received by resident as ordered by physician to remove toxins off their body system and to maintain kidney function. She said if resident missed dialysis treatment, it could potentially lead to fluid overload. She said best nursing practice is to document every dialysis treatment day in resident's health record. V2 said it is standard nursing principle, if it's not documented, it wasn't done. She said R5 is on HD 3x per week Monday/Wednesday/Friday. V2 said on 2/28/25 (Friday), R5 was not able to receive HD due to a transportation issue. V2 said she is not sure if R5 received HD on 3/1/25 and on 3/3/25. V2 stated I don't know why R5 missed dialysis. Surveyor reviewed R5's EHR with V2 and V2 stated unable to find documentation or dialysis assessment if R5 received hemodialysis on 2/28/25 (Friday) and 3/3/25 (Monday) as ordered by physician. MDS (Minimum Data Set) dated 2/27/2025 showed R5's cognition was intact. R5 needed Substantial / maximal assistance with toileting hygiene, shower / bathe self, lower body dressing, chair / bed and toilet transfer. Care plan date initiated on 03/08/2025 showed in part: R5 requires dialysis related to ESRD (End Stage Renal Disease). Assist with arranging transportation to and from dialysis center. Encourage communication with dialysis center. No documentation found in R5's electronic health record that R5 received hemodialysis on 2/28/25 and 3/3/25. No dialysis assessment / dialysis communication found for 2/28/25 and 3/3/25. Facility's Hemodialysis policy dated 7/30/24 documented in part: it is the policy of the facility to ensure that appropriate care for resident on hemodialysis is provided by facility staff. The dialysis nurse will communicate with the facility nurse through a communication sheet or over the phone to ensure continuity of care
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