Failure to Ensure Proper Dialysis Care and Communication
Penalty
Summary
The facility failed to ensure proper dialysis care and communication for a resident with end-stage renal disease and severe cognitive impairment. According to the facility's policy, licensed nurses were required to complete pre-dialysis and post-dialysis communication forms, monitor the resident before and after dialysis, and ensure communication with the dialysis center. Record review showed that for multiple dialysis sessions, there was missing documentation, including absent pre-dialysis, post-dialysis, and dialysis center communication forms. There was also no evidence that nursing staff contacted the dialysis center to obtain reports for several treatment dates. Interviews with staff confirmed that the required forms were not consistently completed and that assessments by licensed nurses were sometimes missed upon the resident's return from dialysis. A private caregiver reported that only CNAs typically took vital signs after dialysis, and licensed nurses did not perform assessments as required. Staff acknowledged the importance of the communication forms and assessments, and confirmed the gaps in documentation and communication for the identified dates.