Failure to Notify Physician of Missed Hemodialysis Treatments
Penalty
Summary
The facility failed to notify a resident's physician when the resident refused to attend scheduled hemodialysis treatments on multiple occasions. The resident, who had diagnoses including diabetes mellitus, congestive heart failure, and chronic kidney disease, was admitted with an order for hemodialysis three times a week. Documentation and interviews revealed that the resident missed dialysis sessions on three separate dates, but the physician was only notified of one of these missed treatments. There was no evidence that the physician was informed about the other two missed sessions. Interviews with nursing staff indicated lapses in communication and documentation. One LVN was unaware that the resident had missed dialysis and was not informed by the previous shift, while another LVN admitted to forgetting to endorse the refusal to the oncoming nurse and did not notify the dialysis clinic or the physician. The dialysis clinic nurse also reported difficulty obtaining information from facility staff regarding the resident's absences and ultimately reported the incident to the California Department of Public Health. The facility's policy and procedure required prompt notification of the attending physician and documentation of any change in the resident's condition, including missed treatments, using the SBAR tool. The Assistant Director of Nursing confirmed that staff were expected to notify both the dialysis clinic and the physician, document the event, and monitor the resident for complications. However, these steps were not consistently followed, resulting in a failure to provide appropriate notification and care according to physician orders and facility policy.