Failure to Provide Prescribed Dialysis Medication and Daily Weights
Penalty
Summary
The facility failed to provide safe and appropriate dialysis care for a resident with end stage renal disease who required hemodialysis. The resident had physician orders and a care plan specifying the need for daily weights and administration of Lokelma (sodium zirconium cyclosilicate) on specific days to manage high potassium levels. Documentation showed that the resident was not weighed on several ordered days in April and May, and multiple scheduled doses of Lokelma were not administered during this period. The medication was prescribed in response to a significantly high potassium level, and the care plan required close monitoring and collaboration with the dialysis center. The Director of Nursing confirmed that there were multiple missed daily weights and missed doses of Lokelma, citing issues with insurance coverage and pharmacy supply for the medication. The facility's own policy required timely medication administration and daily weights for residents receiving hemodialysis, as well as communication with the dialysis center regarding treatment orders and resident status. Despite these requirements, the resident did not consistently receive the prescribed medication or daily weights as ordered by the physician.