Failure to Document Dialysis Assessments and Ensure Communication
Penalty
Summary
The facility failed to ensure that required assessments and documentation were completed for a resident receiving dialysis services. Specifically, there was no documentation of vital signs being obtained after the resident returned from dialysis on multiple occasions, as verified by the Director of Nursing. Additionally, dialysis communication forms sent to the dialysis center were not completed by the center, with missing information such as pre- and post-dialysis weights. The facility's own policy required ongoing monitoring and communication with the dialysis provider, including obtaining reports on the resident's tolerance to the procedure, vital signs, and any necessary follow-up information. The resident involved had a history of end stage renal disease, dependence on dialysis, Parkinson's disease, and other significant medical conditions. Physician orders and care plans specified the need for monitoring, including daily checks for infection at the dialysis port, fluid restrictions, and communication with the dialysis center. Despite these orders and contractual obligations between the facility and the dialysis provider, there was a lack of documented collaboration and communication, as well as incomplete monitoring and documentation of the resident's condition before and after dialysis sessions.