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Based on review of documentation, staff interviews, and review of policies the facility failed to document on the patient's care plan that the patient would receive Peripheral Dialysis (PD) at the facility. There was no documented evidence that the patient participation in the development of his plan of care.

Findings were:

Nursing Care Plan policy reads in part, "The RN collaborates with the individual, family, significant other, and representatives of the interdisciplinary team to formulate a realistic plan that identifies goals/expected outcomes, specific nursing actions and resources to meet the patient/family's needs. He/she intervenes as guided by the individual care plan to promote, maintain or restore the patient's physical and psychosocial function at a realistic and optimal level. Nursing actions are consistent with the admission diagnosis and assessment of the patient to achieve goals. The Nursing Care Plan is integrated into the Interdisciplinary Plan of Care."


The patient's medical record revealed that not all of the patient's medical treatment were identified in the patient's Care Plan. The patient was receiving Peripheral Dialysis at his home for more and year prior to his hospitalization at the facility. The patient was going to continue to receive Peripheral Dialysis during his stay at Vibra Hospital. On 10/13/16 the patient received his PD. Peripheral Dialysis was not identified as the patient's problem, objective, or interventions on the patient's individual Care Plan. There was no documented evidence that the patient or the legal representative was included or that they were proactively involved in the implementation of the patient's care plan.

The above finding was confirmed by the DON on the afternoon of 4/6/17. The DON stated that he was aware that PD was not identified in the patient's plan of care.