Incomplete Dialysis Communication Records for Two Residents
Penalty
Summary
The facility failed to maintain complete and accurate records related to dialysis communication for two residents who required hemodialysis. For one resident, physician orders indicated scheduled dialysis treatments three times per week. However, review of the Hemodialysis Communication Record revealed missing required information on multiple dates, including documentation of new orders received and sent with the patient, comments, shunt site observation, whether ports were capped and completed, whether the patient reported pain, lab values, pertinent observations, staff signature and title, and time. A licensed nurse confirmed the lack of this information in the resident's record. Similarly, another resident with physician orders for dialysis on the same schedule had incomplete documentation in the Hemodialysis Communication Record on at least one occasion. The missing information included the same required elements as above. This deficiency was confirmed through staff interview, indicating a pattern of incomplete record-keeping for residents receiving dialysis services.