HospitalInspections.org

Based on medical record review and interview, facility F1 dialysis nurse failed to ensure that written dialysis orders were followed.

Findings include:
1. Review of P1 MR dialysis orders indicated that the patient was retaining 2500 milliliters (mL) of diasylate from the 7/27/2020 order set that would need to be drained before starting the 7/28/2020 order set. The MR for P1 lacked documentation that the 7/27/20 fluid was drained prior to initiation of 7/28/20 fluid.

2. On 9/22/2020 at 1630 hours, S5, Manager, Dialysis, confirmed that the 7/27/2020 peritoneal dialysis order indicates 2,500 mL's of dialysate fluid would be retained, and drained before the 7/28/2020 order would be initiated. P1 MR does not indicate whether the patient was drained or not on 7/28/2020. S5 confirmed that P1 was not drained before starting the 7/28/2020 peritoneal dialysis fill orders.