Failure to Maintain Ongoing Communication with Dialysis Center
Penalty
Summary
The facility failed to maintain ongoing communication with the dialysis treatment center for two residents with end stage renal disease who required regular dialysis. For both residents, there were active physician orders and care plans specifying the need for communication with the dialysis center using a designated form. However, record reviews revealed significant gaps and incomplete documentation of dialysis communication forms. For one resident, only 23 forms were located over several months, with 5 incomplete and none available for an entire month. For the other resident, only a few completed forms were found for two months, and the last scanned forms in the electronic medical record were from several months prior. Nursing staff reported that they completed the top portion of the dialysis communication form and sent it with the resident, while the dialysis center typically returned their own printed post-dialysis information instead of completing the facility's form. Both sets of documents were sent to medical records, but there was no process for retaining copies on the unit. The Director of Nursing confirmed the facility's responsibility for ensuring completion and proper documentation of dialysis communication forms, but was unable to explain the missing or incomplete records, noting that scanning into the electronic medical record was the responsibility of medical records staff, who were unavailable for interview.