Failure to Perform and Document Pre/Post Dialysis Assessments and Communication
Penalty
Summary
The facility failed to ensure proper communication with the dialysis center and did not perform required pre- and post-dialysis assessments for a resident dependent on renal dialysis. Medical record review showed that the resident, who had multiple diagnoses including end stage renal disease and was cognitively intact, had physician orders for in-center dialysis three times weekly. However, these orders did not specify requirements for pre- or post-dialysis assessments. Documentation revealed that there were no progress notes or assessments related to pre- or post-dialysis care for the resident over a period of several weeks. Further review of dialysis communication records indicated multiple missing communication sheets and numerous instances where pre- and post-dialysis assessments were not documented. Interviews with nursing staff and the DON confirmed that the process was to send a communication sheet with the resident to the dialysis center and to document vital signs, shunt site checks, and any new orders, but this was not consistently done. The facility's own hemodialysis policy required ongoing assessment and communication, including monitoring the access site before and after dialysis, but these steps were not followed as evidenced by the missing documentation and incomplete records.