Failure to Maintain Communication with Dialysis Center
Penalty
Summary
The facility staff failed to maintain ongoing communication with the hemodialysis center for a resident who required dialysis services. The facility's policy on 'Hemodialysis' mandates that residents ordered for dialysis should have continuous communication and collaboration with the dialysis facility regarding their care and services. This communication is to be documented via a written format using a dialysis communication form. However, a review of the resident's 'Dialysis Hand Off Communication Report' forms revealed that the section to be completed by the dialysis center and returned with the resident was left blank for all nine scheduled treatments between January 14 and February 13, 2025. The resident in question, identified as Resident R18, was re-admitted to the facility with diagnoses including end-stage renal disease and low blood pressure. The resident was scheduled to receive dialysis three times a week, as indicated in the physician's order summary and nurse progress notes. Despite this, the necessary communication forms were not completed, as confirmed by the Director of Nursing during an interview. This lack of communication between the facility and the dialysis center constitutes a failure to meet the requirement of ensuring that residents who require dialysis receive services consistent with professional standards of practice and their care plan.
Plan Of Correction
Dialysis book of #R18 reviewed by the Director of Nursing Services, or designee, with the attending physician and dialysis provider. We are unable to correct uncharted documentation from the dialysis center. The facility has determined that residents who receive dialysis have the potential to be affected by poor communication between the nursing facility and the dialysis center. In-service education was conducted by the Director of Nursing Services or designee on dialysis communication to the licensed staff. The dialysis center was informed of the proper procedure as it relates to the nursing facility's documentation and communication. The Director of Nursing Services or designees will review the dialysis communication books of each resident receiving dialysis weekly for four weeks, then bi-weekly for one month to ensure the dialysis center's documentation is complete. Audited records will be reviewed by the Risk Management/Quality Assurance Committee until such time consistent substantial compliance has been achieved as determined by the committee.