Inconsistent Dialysis Communication for Two Residents
Penalty
Summary
The facility failed to ensure consistent communication regarding dialysis treatment for two residents, R113 and R213, who required dialysis services. The facility's policy on 'Dialysis Care' mandates that all residents receiving dialysis therapy be monitored and documented in their medical records, with assessments conducted before and after dialysis treatment. However, for Resident R113, the dialysis communication forms were not completed upon return to the facility following dialysis on ten occasions between January 18 and February 8, 2025. This was confirmed by the Unit Director RN Employee E19 during an interview. Similarly, Resident R213's dialysis communication forms were not completed upon return to the facility following dialysis on seventeen occasions between January 3 and February 10, 2025. This lapse was also confirmed by the Unit Director RN Employee E19. The Director of Nursing acknowledged the facility's failure to maintain consistent dialysis communication for these two residents. Both residents had significant medical conditions, including anemia and end-stage renal disease, necessitating regular dialysis treatment.
Plan Of Correction
1. The facility can not retroactively correct the missed dialysis communication as it relates to R113 and R213. Review of physician orders was completed to ensure physician orders are present for access site monitoring. 2. A house audit was done of residents receiving dialysis to ensure physician orders are present for monitoring of dialysis access site; no issues identified. 3. Director of nursing or designee will in-service licensed nursing staff on completing the bottom section of the dialysis communication form upon return from dialysis. 4. Director of nursing or designee will audit 5 residents weekly for 2 weeks, then 3 residents weekly for 2 weeks, then 3 residents monthly for 2 months to ensure the bottom section of the dialysis communication form is completed. Audit findings will be shared with the QAPI committee.