Failure to Ensure Timely and Accurate Dialysis Medication Administration and Communication
Penalty
Summary
The facility failed to consistently communicate with the dialysis department and follow through on specific medication administration instructions for a resident requiring dialysis. The resident, who was cognitively intact and had diagnoses including end stage renal disease, congestive heart failure, diabetes, and recent post-surgical treatment, was admitted following a hospitalization that included complications related to dialysis such as hypotension and hypoglycemia. The care plan identified the need for a diabetic diet and highlighted the risk for dialysis complications, directing staff to send a communication folder with the resident for each dialysis session. Despite these directives, there were lapses in the communication process. The Dialysis Center Communication Record, which was supposed to accompany the resident to and from dialysis, was missing for some sessions, and the facility was unable to account for all records since admission. Additionally, the communication record from the dialysis center specifically instructed that the resident's Midodrine medication be administered one hour before dialysis. However, the medication administration record (MAR) only indicated "AM" dosing without specifying the required timing, leading to confusion among staff. Interviews revealed that staff sometimes gave the medication with breakfast or at the time of departure, rather than the specified one hour prior, and the order was not clearly written to reflect the dialysis center's instructions. Further, the facility lacked a clear policy beyond the undated communication record document, and the process for reviewing and implementing new orders from the dialysis center was not consistently followed. The director of nursing acknowledged that the medication order should have been more precise and that the review process for dialysis communication records was not fully implemented. The care coordination agreement with the dialysis provider required the facility to ensure residents received necessary medications before dialysis, but this was not reliably achieved for this resident.