Failure to Maintain Ongoing Dialysis Communication
Penalty
Summary
Facility staff failed to maintain ongoing communication with the dialysis center for a resident with end-stage renal disease who was dependent on dialysis. According to facility policy, a dialysis communication binder was to be used for all residents receiving dialysis, with specific sections to be completed by nursing staff before transfer, by the dialysis center, and by nursing staff upon the resident's return. Review of the clinical record showed that the resident was readmitted with diagnoses including ESRD and diabetes, and had physician orders for dialysis three times a week. The care plan required monitoring of vital signs before and after dialysis, assessment of the access area, and daily checks for adequate blood flow. However, review of dialysis communication forms from January through April revealed that 17 out of 47 forms were not fully completed, either by the dialysis center or by facility staff after the resident's return. This incomplete documentation was confirmed by the Assistant Director of Nursing, who acknowledged that the required communication forms were not consistently completed pre- and post-treatment between the facility and the dialysis center.