Failure to Obtain and Maintain Accurate Dialysis Documentation and Orders
Penalty
Summary
The facility failed to ensure complete and accurate dialysis care for a resident requiring such services. Upon review, the facility did not obtain or maintain dialysis treatment documentation (dialysis logs) from the dialysis center for a resident with a central line for dialysis access. The resident, who was cognitively intact and admitted with complex medical conditions, reported that the facility did not communicate with the dialysis center and relied on the resident to provide records. Observation confirmed the presence of a central line, and the resident described their dialysis schedule and location, which matched the care plan but not the physician orders. Further review revealed discrepancies in the resident's medical record, including conflicting information about the dialysis access site, treatment days, and dialysis center location. The physician orders incorrectly referenced an AV fistula and related assessments, which were not applicable to the resident's actual central line access. Facility staff confirmed the inaccuracies and acknowledged the absence of dialysis logs in the resident's record.