Failure to Provide Safe and Coordinated Dialysis Care and Documentation
Penalty
Summary
The facility failed to provide safe and appropriate dialysis care and services for residents requiring such treatment, as evidenced by incomplete records of pre- and post-dialysis assessments, untimely entry of physician orders, and lack of proper coordination with dialysis providers. For three residents with end stage renal disease and dependence on dialysis, the facility did not maintain required documentation, including dialysis communication forms and assessment records. In one case, a resident missed scheduled dialysis sessions due to the facility's failure to timely enter physician orders, resulting in the resident being sent to the hospital for emergent dialysis. Another resident's records showed no updated dialysis communication forms for several months, despite ongoing orders to obtain vital signs before and after dialysis. The Director of Nursing confirmed the absence of complete records for this resident. Additionally, a third resident was observed with a central venous catheter for dialysis that was left uncovered and without a dressing, contrary to standard infection prevention practices. The facility also delayed entering dialysis orders for this resident and failed to provide necessary vaccination status information to the dialysis center. Interviews with facility staff, including the DON, RN Supervisor, and Nursing Home Administrator, confirmed these failures in documentation, order entry, and care coordination. The facility did not ensure that residents received dialysis services as ordered, nor did it maintain ongoing communication and assessment of residents' conditions before and after dialysis treatments, as required by professional standards and facility policy.