Failure to Maintain Dialysis Communication Records
Penalty
Summary
The facility failed to maintain complete and accurate records related to dialysis communication for a resident requiring dialysis services. According to the facility's agreement with the dialysis center, the facility is responsible for providing all relevant medical and administrative information about the resident, while the dialysis center is to supply the facility with updates and guidance regarding the resident's renal condition. However, review of the clinical record for a resident with end stage renal disease and a physician's order for dialysis three times weekly revealed that the dialysis communication binder, which should contain essential information exchanged between the facility and the dialysis center, was not readily available in the facility. Interviews with the resident, the DON, and the Nursing Home Administrator confirmed that the dialysis communication binder could not be located or reviewed at the time of the survey. The resident mentioned that the binder is usually kept in their wheelchair but was unsure of its current location. Both the DON and the Administrator acknowledged that the binder was not accessible, indicating a lapse in maintaining required medical records and communication as stipulated by facility policy and regulatory requirements.