Failure to Coordinate Dialysis Communication
Penalty
Summary
The facility failed to coordinate communication with a dialysis center for a resident requiring dialysis services. The resident, who has end-stage renal disease and is dependent on renal dialysis, was observed not feeling well and expressed uncertainty about attending dialysis. Despite the facility providing transportation, there was a lack of completed communication forms from the dialysis center, which are essential for documenting medications given, vital signs, and any changes in condition. The forms for specific dates were incomplete, and there was no evidence in the progress notes that the facility attempted to contact the dialysis center for the missing information. Interviews with staff revealed that the communication forms were not consistently completed by the dialysis center, and there was no policy in place for dialysis communication. The Director of Nursing acknowledged difficulties in obtaining completed forms from the dialysis center and noted the absence of a facility policy for dialysis. The contract between the facility and the dialysis center requires the interchange of information and collaboration of care, which was not adequately fulfilled, as evidenced by the incomplete communication forms and lack of documented communication efforts.
Plan Of Correction
1. Resident #36 has been discharged from the facility. 2. Director Of Nursing/Designee has conducted a review of current facility residents to verify communication is completed as required. Follow up based on findings. 3. Staff Development Coordinator/Designee has completed education for licensed nurses related to communication requirements. 4. Director Of Nursing/Staff Development Coordinator/Unit Manager/Designee to complete monitoring of residents to verify communication documentation is present weekly x 3 months, then as needed until substantial compliance is achieved. Findings to be reviewed during the monthly Quality Assurance and Performance Improvement Committee Meeting. Modifications implemented as indicated.