Failure to Ensure Safe Dialysis Care and Appropriate Renal Diet Management
Penalty
Summary
The facility failed to ensure that dialysis services for a resident with end stage renal disease were properly completed, including necessary monitoring and communication with the dialysis provider. The resident, who had moderate cognitive impairment and was at risk for fluid overload, was supposed to have pre- and post-dialysis assessment forms completed and returned to the facility after each dialysis session. However, on multiple occasions, these forms were either incomplete or contained inaccurate information, such as incorrect weights. Staff interviews revealed confusion and inconsistency regarding responsibility for obtaining and verifying dialysis information, with some staff stating it was difficult to get forms returned and others unclear about the process for follow-up with the dialysis provider. Additionally, the facility did not ensure that the resident's dietary needs, as communicated by the dialysis center, were met in a timely and accurate manner. The resident was prescribed a renal diet with specific protein recommendations due to elevated phosphorus levels, but meal tickets and staff interviews indicated that the resident often did not receive adequate protein options and was routinely given cottage cheese, a food high in sodium and phosphorus, despite recommendations to limit it. Dietary staff and CNAs were unaware of the need to limit certain foods and had limited knowledge of the resident's specific diet requirements. Communication between the facility's dietary, nursing, and dialysis staff was inconsistent and delayed, resulting in the resident's diet not being updated promptly to reflect current recommendations. Staff acknowledged confusion regarding diet orders and the need for improved training and information sharing related to renal diets. The lack of timely and accurate communication and documentation regarding both dialysis care and dietary management led to the deficiency identified in the report.