Failure to Ensure Post-Dialysis Assessment and Communication
Penalty
Summary
The facility failed to ensure appropriate post-dialysis care and communication for a resident with end stage renal disease who required hemodialysis. Specifically, there was no follow-up with the dialysis center when post-dialysis weights were missing or when the resident's weight remained the same or increased after dialysis sessions, as documented on several occasions. The facility's care plan required obtaining vital signs and weights per protocol, and the facility's policy indicated ongoing communication and documentation with the dialysis center. However, there was no evidence that the facility contacted the dialysis center to clarify missing or abnormal weight documentation. Interviews with facility staff, including a registered nurse and the DON, confirmed that licensed nurses should have communicated with the dialysis center regarding missing or abnormal post-dialysis weights, but no such documentation or communication was provided. The DON acknowledged that the facility is responsible for monitoring and verifying dialysis information, even if it is documented by the dialysis center, and that failure to do so could result in unidentified complications for the resident.