Failure to Document Pre- and Post-Dialysis Assessments
Penalty
Summary
The facility failed to ensure that a resident receiving hemodialysis was properly assessed before and after dialysis treatments. Record reviews showed that on multiple occasions, there was no documentation of pre- and post-dialysis vital signs or observations for the resident. Additionally, there were several dates where no hemodialysis communication documentation was present in the resident's records, despite physician orders specifying the need for regular dialysis treatments. Interviews with facility staff revealed a lack of awareness and education regarding the requirement to complete pre- and post-dialysis assessment forms. The DON acknowledged not having educated nurses on the process, and a LPN described the expected procedure, which was not consistently followed. The facility's own policy required completion of dialysis communication forms and coordination with the dialysis center, but these procedures were not adhered to, resulting in incomplete documentation and assessment for the resident undergoing dialysis.