The confusion at Pelican Ridge Post Acute extended beyond missed tracking. Staff also mixed up critical medical equipment in patient records, incorrectly documenting one resident's dialysis access device as equipment typically used for cancer treatment rather than kidney failure.
LVN 5 worked on September 8 when Resident 18 was scheduled for dialysis but told inspectors she never physically saw him leave the building. When pressed about whether the patient actually attended his appointment, she responded: "I am not 100% sure, it's a blur. I did not see him coming in."
The nurse acknowledged her failure to verify the patient's attendance violated basic protocols. "I should have asked the resident, asked the CNA and called the front desk, if he had dialysis," she told inspectors.
Dialysis is a life-sustaining treatment for patients with end-stage renal disease, filtering waste products and excess fluid that their kidneys can no longer remove. Missing sessions can lead to dangerous buildup of toxins and fluid retention.
CNA 6, who was also questioned about Resident 18's whereabouts on multiple dates, told inspectors: "I don't remember him leaving the building."
The facility's receptionist, who worked both September 5 and September 8, said she never saw Resident 18 waiting in the lobby for dialysis transportation. She explained that if a patient was waiting and not picked up, standard procedure required calling the certified nursing assistant or licensed nurse.
But the communication breakdown extended beyond one patient's missed verification.
Resident 10's medical records contained a potentially dangerous mix-up of medical devices. The patient had end-stage renal disease and required a Perma-Cath in his left thigh for hemodialysis treatments.
However, facility documentation consistently misidentified his dialysis access as a "Port-A-Cath" - a completely different device typically implanted in the chest wall for administering chemotherapy, blood transfusions, or intravenous nutrition to cancer patients.
The error appeared in multiple places. A September 2 dialysis communication form incorrectly specified the patient's vascular access device as a Port-A-Cath. A physician's order dated September 21 for monitoring the patient's dialysis access site also incorrectly identified it as a Port-A-Cath.
The Director of Nursing confirmed the mistake when questioned by inspectors. She verified that Resident 10's dialysis access was indeed a Perma-Cath, not the Port-A-Cath documented throughout his medical records.
The confusion over medical device identification creates risks beyond paperwork errors. Perma-Caths and Port-A-Caths require different monitoring protocols, have different infection risks, and serve entirely different medical purposes. Nurses and doctors relying on incorrect documentation might miss signs of complications specific to the actual device.
Both residents had end-stage renal disease, a condition where kidneys have permanently lost most of their function and can no longer adequately filter waste products from the blood. For these patients, accurate tracking of dialysis attendance and proper identification of vascular access devices can be matters of life and death.
The inspection found the facility failed to ensure residents received necessary care and services. Staff couldn't account for whether one patient attended his dialysis appointments, while another patient's critical medical equipment was misidentified in official records and physician orders.
When contacted by phone after the inspection, both the Administrator and Director of Nursing acknowledged and verified the findings. The facility now faces questions about its basic patient tracking systems and medical record accuracy for some of its most vulnerable residents.
For patients like Resident 18, whose nurse described his dialysis attendance as "a blur," the consequences of such confusion extend far beyond administrative oversight. Without reliable dialysis treatment, waste products and excess fluid accumulate in the body, potentially leading to heart problems, bone disease, and other life-threatening complications.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Pelican Ridge Post Acute from 2025-09-25 including all violations, facility responses, and corrective action plans.