Incomplete Dialysis Communication for Resident
Penalty
Summary
The facility failed to ensure proper communication with the dialysis provider for a resident requiring dialysis, as evidenced by incomplete documentation in the resident's dialysis communication binder. The facility's policy on 'Dialysis Management (Hemodialysis)' mandates that pre-dialysis information be completed by the facility nurse and sent with the resident to the dialysis center on treatment days. However, for Resident R47, who has end-stage renal disease and is dependent on dialysis, the communication pages for several treatment dates were found to be incomplete. Specifically, the facility nurse did not complete the required pre-dialysis information on November 28, December 5, December 30, 2024, and January 23, 2025. Resident R47 entered the facility with a diagnosis of end-stage renal disease, necessitating regular dialysis treatments. The facility's failure to adhere to its own policy resulted in a lack of proper communication between the facility and the dialysis center, potentially impacting the coordination of care for the resident. This deficiency was confirmed by a licensed nurse, unit manager Employee E13, during an interview on January 31, 2025.
Plan Of Correction
This plan of correction is submitted to comply with federal regulations. This plan is not an admission of guilt, or wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. R47 The facility cannot go back retroactively to correct this issue. The DON/designee conducted an audit of residents' dialysis communication binders to ensure that communication pages have complete documentation on them from the facility and the dialysis unit. The DON/designee educated licensed staff on the dialysis policy which includes completing the documentation on the dialysis communication sheet prior to leaving for dialysis and upon returning from dialysis. The DON/designee will audit dialysis communication binders to ensure documentation is complete. Audits will be done weekly for 4 weeks, then monthly for 2 months. Results of these audits will be submitted to the quality assurance committee to determine if further action is needed.