Deficient Communication and Documentation for Dialysis Residents
Penalty
Summary
The facility failed to maintain proper communication and documentation between the facility and a dialysis provider for three residents receiving dialysis. Resident R104, who was admitted with end-stage renal disease, experienced a severe infection at the fistula site and was hospitalized. The facility's records showed incomplete or missing communication with the dialysis center, and the Unit Manager was unable to provide detailed information about the resident's condition or the progression of the infection. Similarly, Resident R139's records revealed incomplete documentation of dialysis sessions. Out of nineteen log pages, only eleven were completed, with one page lacking any clinical information from the dialysis center and ten pages missing post-dialysis documentation from the facility's evening staff. The Unit Manager confirmed these documentation lapses, indicating a failure in maintaining accurate and complete records for residents undergoing dialysis.
Plan Of Correction
Resident R104, R139 and R230 dialysis communication books were reviewed. Residents on dialysis communication books were reviewed and dialysis centers for residents were called to review procedure for post dialysis communication. Staff development nurse/designee re-educated licensed staff on completion of dialysis communication book and checking communication book upon return from dialysis. Unit managers/designee will randomly audit dialysis communication books weekly x 4 then monthly x2 to ensure communication sheets are completed during visits and report results to QAPI committee monthly.