Inadequate Communication with Dialysis Center
Penalty
Summary
The facility failed to ensure consistent communication and collaboration with a community-based dialysis center for a resident requiring hemodialysis, leading to incomplete documentation of vital signs and weights for 25 out of 34 dialysis sessions. The facility's policy required that a hemodialysis report be completed and sent with the resident to the dialysis center, and upon the resident's return, the report should be reviewed, and any new recommendations confirmed with the primary physician. However, the dialysis report sheets frequently lacked complete documentation, and there was no evidence of follow-up communication with the dialysis center regarding these omissions. Resident #65, who had diagnoses of end-stage renal disease, diabetes, and hypertension, was affected by this deficiency. Despite the facility's policy and physician orders requiring vital signs and weights to be documented before and after dialysis, the interdisciplinary progress notes did not reflect any communication with the dialysis center to address the incomplete reports. Interviews with facility staff revealed that the process for reviewing and following up on dialysis reports was not consistently followed, and there was an assumption that if the dialysis center did not call, everything was fine, even if the report sheet was blank.
Plan Of Correction
Plan of Correction: Approved February 17, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Resident identified as #65 continues on [MEDICAL TREATMENT] treatment. Resident #65’s order for the [MEDICAL TREATMENT] communication book to be returned and completed and advised to contact [MEDICAL TREATMENT] office directly if incomplete. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: Currently no other residents require [MEDICAL TREATMENT]. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur: LPN and RN staff to be educated on [MEDICAL TREATMENT] policy. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice: An audit to monitor [MEDICAL TREATMENT] communication book will be completed weekly for three months, monthly for three months, and quarterly for six months and reported to QAPI. The date for correction and the title of the person responsible for correction of each deficiency: Director of Nursing.