Failure to Ensure Consistent Communication with Dialysis Center
Penalty
Summary
The facility failed to ensure consistent communication with the dialysis center for a resident who required hemodialysis. The resident, who had end stage renal disease, chronic kidney disease Stage V, and was dependent on hemodialysis, had physician's orders to receive dialysis three times a week. The care plan specified coordination with the dialysis center and required the center to forward dialysis treatment notes to the facility. However, review of the resident's records over a 30-day period showed that out of 13 dialysis treatments, only six treatment sheets were available, and several of those were incomplete. Seven treatment dates had no documentation at all, and among the available sheets, key sections such as medications administered, new orders, and any problems during treatment were often left blank. Staff interviews confirmed that the dialysis center frequently failed to send back completed treatment sheets, and when documentation was received, it was often limited to pre- and post-dialysis weights and vital signs. The facility staff had to search the resident's belongings for any paperwork and sometimes had to call the dialysis center to request missing information. The facility's policy required comprehensive monitoring and communication with the dialysis center, including receiving reports after each dialysis visit, but this was not consistently followed.