Failure to Clarify and Implement Dialysis Medication Orders
Penalty
Summary
The facility failed to ensure that dialysis orders regarding the holding of medications were clarified and properly implemented for a resident with end stage renal disease and multiple comorbidities, including heart failure, diabetes, and liver disease. Medical record review showed that after the resident's readmission, there was no evidence of physician orders to hold medications on dialysis days, yet staff continued to withhold all morning medications on those days. This practice occurred repeatedly over several months, as documented in the medication administration records, without any supporting physician order. Interviews with the DON confirmed that staff were following an outdated order from a previous admission and had not obtained clarification or new orders from the physician or dialysis center. The DON acknowledged that staff held all morning medications on dialysis days in February, March, and April without a current physician order. The facility's policy required coordination with the dialysis center and provider regarding medication administration times, but this was not followed, resulting in the deficiency.