Failure to Ensure Proper Dialysis Care and Medication Management
Penalty
Summary
The facility failed to ensure that a resident requiring dialysis received services consistent with professional standards of practice and the comprehensive person-centered care plan. The resident, who was diagnosed with hypertension, end-stage renal disease, and diabetes, experienced a significant weight gain of 17.1 pounds over a short period. Despite the facility's policy requiring physician notification for weight gains greater than five pounds, there was no evidence that the physician was informed of this change in the resident's condition. Interviews with staff revealed that the responsibility for notifying the physician was not fulfilled, as the dietician did not alert the RN, and consequently, the RN did not contact the doctor. Additionally, there was a failure in medication management for the resident. The facility did not correctly enter the resident's medication order for cinacalcet, which was to be administered on specific days in relation to dialysis sessions. The Director of Nursing confirmed that the medication order was not entered correctly, which further indicates a lapse in ensuring that the resident received dialysis services in accordance with professional standards and the care plan.
Plan Of Correction
Resident #45 was immediately re-weighed, and findings were communicated to the physician. The medication order was reviewed for accuracy and updated as necessary. To identify other residents that have the potential to be affected, the DON/designee reviewed all residents receiving dialysis services to ensure orders are followed, notifications made to physician for weight change and change in condition. Corrections will be made as needed. To prevent this from recurring, the DON/designee educated licensed nurses on regulatory requirements of F698 ensuring residents receiving dialysis services that orders are followed, and notifications made to physician for weight change and change in condition. To monitor and maintain ongoing compliance, the DON/designee will audit current residents on dialysis communication binder upon return from dialysis for any new order recommendations weekly x4 weeks then monthly x2 to ensure orders are followed, and that physician is notified of weight change and changes in condition. Negative findings will be addressed. Ad Hoc education will be provided as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.