Inconsistent Dialysis Communication for Resident with ESRD
Penalty
Summary
The facility failed to maintain consistent communication regarding dialysis care for a resident with end-stage renal disease (ESRD). According to the facility's policy, residents with ESRD should be cared for according to recognized standards, including clear communication between the facility and the contracted dialysis provider. However, the clinical record for a resident admitted in August 2024, who was dependent on renal dialysis, showed incomplete documentation of User-Defined Assessments (UDA) for several dates in January 2025. Specifically, there were missing post-dialysis communication assessments on five occasions and missing pre and post-dialysis assessments on two occasions. During an interview, a registered nurse confirmed the absence of the required communication documentation for the specified dates. The resident's medical history included peripheral vascular disease and heart failure, and they attended dialysis sessions three times a week. The lack of complete documentation indicates a failure to adhere to the facility's policy and professional standards of practice, as well as the comprehensive person-centered care plan for the resident.
Plan Of Correction
Resident R1 remains in the facility and had no negative outcomes from the missing documentation. The DON or designee will audit all dialysis residents for concerns of missing UDA forms. The DON or designee will educate all licensed staff on completing dialysis UDA forms and auditing to ensure return UDA forms are completed upon return to the facility. The DON or designee will audit all dialysis communication forms for completion daily x3 days, then five resident charts weekly for 8 weeks. All results to be reviewed through QAPI for further recommendation.