Failure to Ensure Consistent Communication for Dialysis Care
Penalty
Summary
The facility failed to ensure consistent and accurate communication between the facility and the dialysis center regarding a resident's health information and hemodialysis treatments. The resident, who had diagnoses including paraplegia, end stage renal disease, acute kidney failure, and type 1 diabetes mellitus with hypoglycemia, had physician orders for hemodialysis twice weekly at an outside facility, with specific instructions for sending a dialysis book, obtaining pre- and post-dialysis vital signs and assessments, and checking the dialysis site. However, review of the dialysis communication binder revealed only five communication forms for a four-month period, with several forms either incomplete, missing required information such as names, dates, or nurse signatures, or left entirely blank for both pre- and post-dialysis documentation. Interviews with the DON and a dialysis RN confirmed that the communication forms were not consistently completed or sent with the resident, and that the dialysis center did not always receive the necessary information. The DON acknowledged the lack of complete documentation and stated that the communication binder had only recently been implemented due to previous issues obtaining notes from the dialysis facility. Facility policy required facilitation of outpatient dialysis services to ensure uninterrupted care, but the observed documentation practices did not meet these requirements.