Failure to Maintain Effective Communication and Documentation for Dialysis Residents
Penalty
Summary
The facility failed to maintain effective communication and documentation with the dialysis provider for two residents requiring dialysis services. For one resident, the required communication binder, which contains essential information and communication pages between the facility and the dialysis team, could not be located on the nursing unit. Staff confirmed that the binder was not available and was not with the resident as required. This binder is intended to ensure ongoing assessment and monitoring of the resident's condition before and after each dialysis treatment, as outlined in the facility's policy. For another resident, review of the dialysis communication binder revealed incomplete documentation on multiple occasions. Specifically, only the pre-dialysis section was completed with vital signs and a nurse's signature, while the sections to be completed by the dialysis nurse and the post-dialysis evaluation by the facility nurse were left blank on several dates. Staff interviews confirmed that the protocol requires nurses to document pre- and post-dialysis assessments in the binder, but this was not consistently done. Both residents had significant medical histories, including kidney disease, diabetes, and dependence on dialysis, underscoring the importance of thorough communication and documentation.