Failure to Maintain Consistent Dialysis Communication Documentation
Penalty
Summary
The facility failed to maintain consistent and complete dialysis communication for two residents who required regular dialysis treatments. According to facility policy, licensed staff are required to complete a Dialysis Communication Form prior to each transfer to the dialysis clinic and upon the resident's return, ensuring all relevant treatment information is documented and filed in the clinical record. For one resident with diagnoses including renal failure, stroke, and hemiplegia, the clinical record was missing complete communication forms for thirteen separate dialysis dates. This was confirmed by a registered nurse who acknowledged the absence of the required documentation on those dates. A second resident, diagnosed with high blood pressure, hyperlipidemia, and end-stage renal disease, also had incomplete dialysis communication forms for three treatment dates. The care plan for this resident specified that the entire first page of the communication form should be completed and passed to the next shift nurse, but this was not consistently done. A licensed practical nurse confirmed the missing documentation for the identified dates. These findings indicate that the facility did not ensure consistent communication and documentation for residents receiving dialysis, as required by facility policy and state regulations.