Failure to Maintain Accurate Communication and Coordination for Dialysis Care
Penalty
Summary
The facility failed to maintain ongoing communication, coordination, and collaboration between the nursing home and the dialysis staff for a resident with End Stage Renal Disease who required dialysis. The resident had a documented Do Not Resuscitate (DNR) order in the facility's electronic medical record, but the dialysis communication binder, which travels with the resident to the dialysis center, incorrectly indicated a full code status and contained outdated physician orders and medication lists. The LPN responsible for updating the binder confirmed that the information was not current, and the DON and Regional Nurse stated that they believed it was the dialysis center's responsibility to manage advanced directives, not the facility's. The dialysis center nurse reported that the communication binder is their primary means of receiving information from the facility and that there was no record of advanced directives or care meetings in their chart. Additionally, the resident was noted to have mild cognitive impairment and episodes of confusion, particularly during dialysis. Despite an assessment indicating the resident should not self-administer medications, the communication binder included instructions for the resident to self-administer Sevelamer at dialysis, and the MAR reflected that the medication was sent with the resident. Staff interviews revealed confusion about the resident's dialysis schedule and medication administration responsibilities, further demonstrating a lack of effective communication and coordination between facility staff and the dialysis center.