Inconsistent Dialysis Communication for Resident
Penalty
Summary
The facility failed to ensure consistent communication regarding dialysis care for a resident requiring such services. Resident R64, who was admitted with diagnoses of heart failure, renal failure with dialysis, and high blood pressure, had physician orders to attend dialysis sessions three times a week. However, a review of the clinical records revealed incomplete communication forms for several dates in December 2024, specifically on 12/6, 12/9, 12/11, 12/13, 12/16, and two additional forms without dates. These forms, which are essential for maintaining proper communication between the nursing home and dialysis providers, were not fully completed by the nursing home staff. Interviews with a Licensed Practical Nurse and the Nursing Home Administrator confirmed the lack of complete communication forms for Resident R64, indicating a failure in maintaining consistent dialysis communication as required.
Plan Of Correction
R64 suffered no adverse effects due to communication binder not being completely filled out. Communication book updated retroactively to reflect missing dates. Education was immediately provided to nursing staff and will be completed on the importance of utilizing the communication binder by DON or designee on or before 2/11/2025. Audits will be completed by DON or designee on communication binder to ensure consistent dialysis communication 3 x weekly for 4 weeks and monthly x 1 month. Audit results will be reviewed through the monthly QAPI process/meeting.