Lack of Ongoing Assessment and Communication for Dialysis Care
Penalty
Summary
The facility failed to establish and implement a system for ongoing assessment and monitoring of a resident with end stage renal disease who required regular dialysis treatments. Review of the resident's medical record showed that there was no documented communication between the facility and the dialysis center before and after dialysis sessions, including assessments of the resident's health status. The resident was readmitted with a diagnosis of end stage renal disease and was scheduled for dialysis three times per week, as indicated in the physician's orders. Interviews with facility staff, including the Unit Clerk, Infection Preventionist, and DON, revealed that there was no specific process or documentation system in place for communication with the dialysis center. Staff were unable to locate any records of pre- or post-dialysis communication or assessments in either the electronic medical record or the hard chart. The facility did not have a documented policy or procedure for dialysis communication until after the deficiency was identified.