Failure to Maintain Communication and Monitoring for Dialysis Care
Penalty
Summary
The facility failed to ensure proper communication and monitoring between the facility and the dialysis center for a resident with end stage renal disease who was dependent on dialysis. The resident's care plan required regular communication with the dialysis center, monitoring of the vascular access site, and documentation of post-dialysis observations. However, review of the medical record showed that dialysis communication was only documented on two occasions, with no additional evidence of ongoing communication or documentation in the resident's record or the facility's dialysis communication book. Interviews with staff revealed that the resident consistently refused to have vital signs taken before and after dialysis and would not return the dialysis communication sheets from the dialysis center. The RN confirmed that no communication or documentation was provided upon the resident's return from dialysis, and the DON acknowledged that the facility did not retain copies of the communication sheets nor did they reach out directly to the dialysis center. Facility policy required documentation of dialysis-related care and communication, but this was not consistently followed for the resident in question.