Failure to Document Post-Dialysis Assessments
Summary
The facility failed to complete post-dialysis assessments for a resident with end-stage renal disease, who required dialysis services. The resident, identified with moderate cognitive loss, had a care plan that included dialysis sessions three times a week. The facility's records indicated an order for vital signs to be taken before and after dialysis sessions. However, there were multiple instances where post-dialysis vital signs were not documented, specifically on four occasions in October and November 2024. Interviews with staff revealed that the post-dialysis assessments were supposed to be documented on a dialysis communication sheet or in the electronic health record. However, these assessments were missing from both the communication records and the electronic health record for the specified dates. The Director of Nursing acknowledged that if the assessments were not documented, they were likely not performed. The facility did not have a specific dialysis assessment policy in place, which contributed to the oversight in documentation.
Penalty
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Facility staff failed to provide safe and appropriate dialysis care for three residents by not obtaining necessary physician orders for fistula monitoring, not arranging transportation for dialysis appointments, and not monitoring dialysis access sites or notifying medical providers when a resident declined treatment. Interviews and record reviews confirmed these deficiencies in care and documentation.
A resident with ESRD requiring hemodialysis did not have complete dialysis communication forms filled out on multiple treatment days, despite physician orders and facility policy mandating this documentation. Review of records showed several instances where pre-dialysis or dialysis communication was missing, and staff confirmed the expected process was not consistently followed.
A resident with end-stage renal disease missed multiple dialysis appointments due to the facility's failure to provide appropriate transportation for his height and wheelchair needs, despite his repeated complaints. Staff attributed missed treatments to resident refusal without validating his concerns, and the facility also failed to maintain adequate communication and documentation with the dialysis center, resulting in incomplete records of labs and medications.
Facility staff did not coordinate care with the dialysis center for a resident with end stage renal disease, failing to obtain and document pre- and post-dialysis weights as required by policy. The dialysis book meant to accompany the resident was left blank, and staff interviews confirmed that necessary paperwork and communication with the dialysis provider were not consistently completed.
Facility staff did not maintain ongoing records of communication with the dialysis center for two residents with end stage renal disease. For one resident, communication notes were missing for two dialysis dates, and for another, notes were absent for an entire week, despite care plans requiring coordination and documentation. Staff interviews confirmed the missing records and inability to locate them in either the communication book or electronic medical records.
Facility staff did not maintain complete communication records with the dialysis center for a resident with ESRD, as required by physician orders and facility policy. Several dialysis communication sheets were missing, and staff confirmed they could not provide the missing documentation.
Failure to Provide Safe and Appropriate Dialysis Care and Services
Penalty
Summary
Facility staff failed to provide appropriate dialysis care and services for three residents requiring dialysis. For one resident, there was no physician order for staff to monitor the dialysis fistula site in the left upper arm following readmission from the hospital. The resident reported that only dialysis staff checked the site, and facility staff rarely did so. A review of the clinical record confirmed the absence of orders for monitoring the fistula site, and staff interviews revealed that the omission was due to the admitting nurse forgetting to add the order upon readmission. Another resident did not have transportation arranged to attend scheduled dialysis appointments. The administrator stated that the facility was unaware the resident was a dialysis patient upon admission and encountered difficulties arranging stretcher transport and coordinating with the dialysis center. The director of nursing and transport coordinator confirmed that no transport was set up for the resident at the required time, and there was no documentation of transport arrangements for that period. For a third resident, staff failed to monitor the dialysis access port according to professional standards and did not notify the medical provider when the resident declined a dialysis session. The clinical record only noted the presence of a fistula in the admission assessment and care plan, with no documentation of regular monitoring for thrill and bruit or related physician orders. When the resident refused dialysis due to feeling unwell, staff did not inform the medical provider, despite acknowledging the importance of such notification. Interviews and record reviews confirmed the lack of documentation and communication regarding the missed dialysis session and access site monitoring.
Failure to Complete Required Dialysis Communication Documentation
Penalty
Summary
Facility staff failed to provide complete dialysis communication for a resident with end stage renal disease (ESRD) who required hemodialysis and had a left arm AV fistula. According to the clinical record and physician orders, staff were required to complete a dialysis communication form and record vital signs prior to transporting the resident to dialysis on each treatment day. However, review of the Hemodialysis Communication Records revealed multiple instances across November, December, and January where pre-dialysis or dialysis communication forms were not completed as required. The resident's care plan documented the ongoing need for hemodialysis, and staff interviews confirmed the process for completing and transmitting dialysis communication forms. Despite this, there were several dates where no documentation was present, indicating a failure to follow established protocols and facility policy, which required routine communication of relevant information to the dialysis center on treatment days.
Failure to Ensure Safe Dialysis Transportation and Communication
Penalty
Summary
Facility staff failed to ensure a resident requiring dialysis received appropriate transportation and ongoing communication and collaboration with the dialysis center. The resident, who was non-weight bearing due to wounds and osteomyelitis and had multiple comorbidities including end-stage renal disease, repeatedly missed dialysis appointments because the transportation provided was not suitable for his height and high-backed wheelchair. Despite the resident's repeated complaints to staff about the inadequacy of the vehicles, no measurements were taken to validate his concerns until after multiple missed appointments. Staff and leadership characterized the missed appointments as refusals, but documentation and interviews revealed the resident was willing to attend dialysis if appropriate transportation was provided. The facility also failed to maintain effective communication with the dialysis center regarding the resident's care. The communication book sent with the resident to dialysis was largely incomplete, with only vital signs recorded and no documentation of medications administered, lab results, or other pertinent information. The facility did not consistently receive or document lab results or medication administration from the dialysis center, and there was no evidence of proactive follow-up by facility staff to obtain this information. The DON acknowledged that the expected process for communication and documentation was not followed. Additionally, the facility's own policies required coordination of transportation and communication with outside providers, but these procedures were not adhered to. The lack of proper transportation arrangements and incomplete communication with the dialysis center led to missed treatments and gaps in the resident's clinical record, including missing lab results and medication documentation. These failures persisted until the resident was finally measured and appropriate transportation was arranged, but not before multiple missed dialysis sessions and incomplete clinical information.
Failure to Coordinate Dialysis Care and Document Required Weights
Penalty
Summary
Facility staff failed to coordinate care with the dialysis center for a resident diagnosed with end stage renal disease who required dialysis three times a week. The resident's care plan included interventions to coordinate care with the dialysis provider as needed, and facility policy required obtaining pre- and post-dialysis weights and ensuring communication with the dialysis center. However, during clinical record review, there was no documentation of pre- or post-dialysis weights for the resident, and the dialysis book intended to accompany the resident to dialysis contained only blank pages. Interviews with staff revealed that required paperwork was not consistently sent with the resident to dialysis, and staff did not obtain or document the necessary weights as outlined in facility policy. The absence of completed documentation and lack of coordination with the dialysis center were confirmed by both the Assistant Director of Nursing and the Unit Manager. No further information or documentation regarding the coordination of care was provided to the survey team prior to the exit conference.
Failure to Maintain Ongoing Dialysis Communication Records
Penalty
Summary
Facility staff failed to maintain ongoing records of communication between the facility and the dialysis center for two residents requiring dialysis services. For one resident with end stage renal disease, there were no communication notes from the dialysis center for two specific dates, despite the resident attending dialysis on one of those days and missing the other due to a dermatology appointment. The resident's care plan included coordination with dialysis as needed but did not specify ongoing communication, coordination, or collaboration between the facility and the dialysis center. Staff interviews confirmed the absence of communication notes and the inability to locate them in the communication book or electronic records. For another resident with end stage renal disease receiving in-house dialysis, there were no communication notes from the dialysis center for the last week of February. The resident reported receiving dialysis services Monday through Friday and carrying the communication book to and from dialysis. The care plan required that the dialysis communication record be sent and returned with each appointment, but staff confirmed the absence of notes for the specified period, attributing it to the need for uploading into the electronic medical records. No further information or comments were provided by facility leadership during the final interview.
Failure to Maintain Required Dialysis Communication Documentation
Penalty
Summary
Facility staff failed to provide adequate dialysis care and services for one resident with end stage renal disease, congestive heart failure, and diabetes mellitus. The resident required regular hemodialysis and had physician orders for transportation to a dialysis center and daily checks of the AV fistula site. The resident's care plan included instructions to confer with the physician or dialysis center regarding medication adjustments as needed before dialysis. However, a review of facility-to-dialysis center communication sheets revealed that several required communication records were missing for a significant period. Interviews with the resident and facility staff confirmed that the communication documentation was incomplete, and the facility was unable to provide the missing dialysis communication sheets when requested. The facility's own policy required ongoing communication and coordination with the contracted dialysis center, but there was no evidence that this process was consistently followed for the resident in question.
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