Failure to Maintain Accurate Dialysis Records
Penalty
Summary
The facility failed to maintain complete and accurate records related to dialysis communication for Resident 96, who required dialysis services. The facility's policy on Dialysis Management, revised in March 2024, mandates the exchange of necessary information for resident care, including the completion of a dialysis communication form by the dialysis center personnel and its subsequent review by the facility. However, the review of Resident 96's clinical records revealed that the dialysis communication sheets were not completed for multiple dates in January and March 2025. Additionally, the facility did not document the resident's post-dialysis dry weight as per physician orders on several occasions in January 2025. Resident 96 had multiple diagnoses, including congestive heart failure, diabetes mellitus, chronic kidney disease stage 5, and bipolar disorder, necessitating regular dialysis sessions. Despite the physician's orders for dialysis on specific days and the requirement to record the resident's dry weight post-dialysis, the facility failed to adhere to these orders. Interviews with the Director of Nursing (DON) confirmed the lapses in completing the dialysis communication sheets and obtaining the dry weight, acknowledging that the facility had contacted the dialysis center to address the issue of incomplete post-dialysis vital sign documentation.
Plan Of Correction
This provided submits the following plan of correction in good faith and to comply with Federal regulations. This plan is not an admission of wrongdoing nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. 1. Resident 96's physician was notified that the dry weight per physician order was not documented on Monday evening shift on January 6th, 20th and 27th, 2025. Resident 96's physician and dialysis center was notified that communication sheets were not completed on the following dates in January 2025: 1st, 3rd, 8th, 10th, 13th, 15th, 17th, 20th, 22nd, 24th, 27th, 29th and the 31st. In March 2025: 12th and 14th. 2. To identify other residents that have the potential to be affected, the DON/designee will audit dialysis residents to ensure physician orders are being followed in regards to documenting resident's dry weight. The DON/designee will also audit dialysis resident's communication sheets to ensure they are completed. 3. Staff will be educated by staff development/designee on the importance of following physician orders in regards to taking dry weights. The DON/designee will contact dialysis centers and educate them on the importance of completing communication sheets. The DON/designee will educate licensed staff on contacting the dialysis center when communication sheets are not completed. 4. The DON/designee will conduct an audit 1x a week for 4 weeks on dialysis residents to ensure their dry weights are taken per physician orders as well as audit dialysis communication sheets to ensure they are completed by the dialysis center. Results of the audits will be reviewed at the QAPI meeting to determine if future action/audits are needed.