Failure to Adjust Medication Times for Dialysis Schedule
Penalty
Summary
The facility failed to ensure that medication administration times were adjusted to accommodate a resident's hemodialysis schedule, as per professional standards of practice. This deficiency was identified for a resident with a primary diagnosis of anemia and end-stage renal disease, who required hemodialysis three times a week. The resident's care plan included an intervention to confer with the physician or dialysis center regarding changes in medication administration times as needed. However, the review of the electronic Medication Administration Record (eMAR) indicated that the resident did not receive prescribed medications, clonidine and isosorb dinitrate-hydralazine, on several occasions because the resident was off the unit for dialysis. The Licensed Practical Nurse (LPN) familiar with the resident confirmed that the resident was not receiving these medications while at dialysis and acknowledged the need to clarify the orders with the physician. The Nurse Manager also confirmed that the resident should be receiving the medications as ordered and intended to speak with the doctor to adjust the medication times to align with the dialysis schedule. The facility's policy on hemodialysis, revised in June 2024, stated that medication times might be altered based on dialysis times, but this was not adhered to in practice.
Plan Of Correction
F698- Dialysis What corrective action will be accomplished for those residents affected by the deficient practice? Nurse Manager spoke to the Primary Care Physician clarified and changed Resident #43 medication times of NU EX Order 26.4 (b) and NJ Ex Order 26.4(b)(1) to coincide with NJ Ex Order 26. hours and days. Educated RN/LPN assigned to Resident #43 on the Policy for NJ Exec Order 26.451 Given specific instructions on scheduling meds to coincide with resident dialysis hours and days. How will the facility identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? All residents on hemodialysis have the potential to be affected. What measures will be put into place or what systemic changes will be made to ensure the deficient practice will not recur? The Dialysis Policy was reviewed. Nurse Educator conducted education to RN/LPN/Unit Manager/Nursing Supervisor on the Policy for Dialysis. Education on specific instructions regarding scheduling medications to coincide with resident dialysis hours and days. Unit Managers or designee will monitor dialysis residents medication orders to ensure times are scheduled around Dialysis days and hours. How will the corrective action be monitored to ensure the deficient practice will not recur? Audits will be conducted by Nursing Administration on medication schedules coinciding with dialysis hours and days. The audits will be completed weekly x4, then monthly x3. The results of the audit will be reviewed at the monthly QAPI Committee chaired by the facility administrator.