Failure in Communication and Documentation for Dialysis and Resident Care
Penalty
Summary
The facility failed to notify the doctor of a change in condition, document an assessment or interventions related to blood glucose, and follow physician orders for two residents. These deficiencies were confirmed by the Director of Nursing during an interview. Additionally, the facility did not maintain ongoing communication with the dialysis center for a resident with end-stage renal disease, high blood pressure, and depression. This resident was supposed to receive dialysis three times a week, with vital signs taken before and after each session. The facility's policy required that residents receiving dialysis be monitored and documented in their medical records, with assessments conducted before and after dialysis treatments. However, a review of the dialysis communication forms revealed that 34 out of 156 scheduled treatments were not fully completed, either before or after treatment. This lack of documentation was confirmed by the Director of Nursing, indicating a failure to ensure proper communication between the facility and the dialysis center.
Plan Of Correction
The facility will ensure ongoing communication with the dialysis centers for residents. The facility cannot retroactively correct the concern identified for resident R2. The facility will complete a house audit on all residents who receive dialysis to validate that a dialysis communication form is completed pre and post treatment between the facility and dialysis center. The Director of Nursing or Designee will re-educate licensed nurses, including new hires and agency staff, on the facility policy and procedures for dialysis care, detailing the importance of ensuring the communication form is completed pre and post dialysis treatment between the facility and dialysis center for each scheduled dialysis day. The Director of Nursing or Designee will complete an audit three times a week for four weeks, then monthly, to validate the dialysis form is completed for residents who receive dialysis. The results of these audits will be forwarded to the monthly Quality Assurance and Performance Improvement Committee for review and frequency of audits.