Failure to Document Post-Dialysis Weight for Resident Receiving Hemodialysis
Penalty
Summary
The facility failed to ensure that a post-dialysis assessment was completed for a resident with end stage renal disease who required hemodialysis. Specifically, on 5/15/2025, the dialysis center did not record the resident's post-dialysis weight on the Dialysis Communication Record. This omission was verified during record reviews and interviews with both a registered nurse and the Director of Nursing, who confirmed that the post-dialysis weight was missing and that the facility's protocol required staff to contact the dialysis center to obtain this information if it was not documented. The resident involved was severely cognitively impaired and dependent on staff for daily activities, as indicated by the Minimum Data Set. The resident's care plan required pre- and post-dialysis weights to be taken at the dialysis center to help avoid fluid overload. Facility policy and licensed nurse competency guidelines both specified that missing post-dialysis weights should be immediately followed up with the dialysis center, but this was not done, resulting in incomplete documentation for the resident's dialysis care on the specified date.