Failure to Complete Pre-Dialysis Assessment for Resident
Penalty
Summary
The facility failed to provide ongoing assessment and monitoring for a resident receiving dialysis, as required by professional standards of practice and the resident's care plan. The facility's policy, titled "Dialysis: Hemodialysis- Communication and Documentation," mandates that staff complete the pre-dialysis portion of the Hemodialysis Communication Record to assess the resident's status before sending them to dialysis. However, a review of clinical records revealed that for one resident with end-stage renal disease and a physician's order for dialysis three times a week, the pre-dialysis communication forms were not completed on five out of 14 occasions over a one-month period. This deficiency was confirmed by the Director of Nursing during an interview.
Plan Of Correction
1. The facility is unable to correct the cited deficient practice for Resident 70 due to documentation was for an appointment that happened in the past. 2. Current residents receiving dialysis have been reviewed to verify completion of the pre-dialysis portion of the Hemodialysis Communication form. 3. NPE or designee will re-educate licensed nursing staff on completion of dialysis communication forms. Residents receiving dialysis will be reviewed during clinical meeting to verify completion of the hemodialysis communication forms. 4. DON and/or designee will conduct audits weekly x 8, then monthly x 2 for residents on dialysis to ensure communication forms are being completed. Results of the audits will be presented at the QAPI meetings for review and/or recommendations.