Failure to Ensure Hemodialysis Services Provided as Ordered
Penalty
Summary
A deficiency occurred when a resident with end stage renal disease and multiple comorbidities, including dependence on renal dialysis, was not provided with hemodialysis services three times weekly as ordered by the physician. Documentation revealed that the resident missed a scheduled dialysis session due to a transportation issue, and there was no evidence in the electronic health record that the physician was informed of the missed treatment. Additionally, there was no documentation confirming whether the resident received dialysis on the rescheduled date or on the following scheduled dialysis day. Nursing staff interviewed were unable to verify or locate records indicating that the resident received the required treatments on those days. The facility's policy required that dialysis communication and assessments be completed and documented for each dialysis session, and that the physician be notified if a session was missed or refused. However, review of the resident's records showed no dialysis assessments, progress notes, or communication for the dates in question. The Director of Nursing confirmed the absence of documentation and was unable to explain why the resident missed dialysis or whether the treatments were provided as ordered.