Failure to Ensure Complete Dialysis Assessment and Documentation
Penalty
Summary
The facility failed to ensure that three residents who required dialysis services were properly assessed before, during, and after their dialysis treatments, and that all required documentation was maintained in their medical records according to facility policy. Specifically, the care plans for these residents indicated that nurses were to document the time, date, and general condition of the residents before transport to dialysis, as well as upon their return. However, reviews of the residents' medical records revealed missing or incomplete documentation, including absent pre- and post-dialysis evaluations and missing treatment records from the dialysis center. Resident 10, who had diagnoses including type 2 diabetes mellitus, respiratory failure, and dependence on renal dialysis, was admitted and readmitted to the facility and was scheduled for dialysis three times a week. The care plan required documentation of the resident's condition before and after dialysis, but the pre-dialysis evaluation form was found incomplete, with the section to be filled by the dialysis unit left blank. Similarly, Resident 11, with diagnoses of type 2 diabetes mellitus and end stage renal disease, was also scheduled for regular dialysis, but their medical record was missing post-dialysis evaluations for several dates, and the dialysis unit's section on the pre-dialysis evaluation forms was not completed. Resident 12, who had type 2 diabetes mellitus, end stage renal disease, and muscle weakness, was also scheduled for dialysis three times a week. The medical record for this resident did not include any documentation from the dialysis center for two treatment dates. Interviews with facility staff confirmed that the required documentation was either incomplete or missing, and that the dialysis center's nurse had not completed the necessary sections of the forms as required by facility policy. The facility's policy and procedure on dialysis management specified that all documentation concerning dialysis services and care should be maintained in the resident's medical record, and that communication forms should be sent to and completed by the dialysis center for each treatment.