Failure to Document and Communicate Dialysis Care
Penalty
Summary
The facility failed to ensure proper documentation and communication regarding dialysis care for a resident dependent on hemodialysis. Review of the resident's records showed that pre- and post-dialysis assessments, including vital signs and weights, were not consistently documented as required by facility policy and physician orders. The care plan for the resident did not address communication between the dialysis center and the facility, and there was a lack of completed dialysis communication forms in the resident's binder since October of the previous year. Interviews with nursing staff revealed confusion and inconsistency regarding who was responsible for preparing and sending the dialysis communication forms. Some staff members stated they completed the forms and sent them with the resident, while others denied involvement or were unsure of the process. The resident reported that vital signs were not always checked before and after dialysis and that the dialysis binder had not been updated or used by staff for several months. Further interviews with the Director of Nursing and Assistant Director of Nursing confirmed that the expectation was for staff to use the communication forms and document pre- and post-dialysis assessments. However, they acknowledged that no completed forms had been located for the resident since October, and that staff often relied on the dialysis center to monitor vital signs and weights. This lack of documentation and communication had the potential to affect the health of residents receiving dialysis.