Failure to Follow NPO Orders and Complete Dialysis Documentation
Penalty
Summary
The facility failed to follow physician orders and complete required documentation for a resident receiving dialysis services. Specifically, the resident was ordered to be NPO (nothing by mouth) after midnight prior to a scheduled medical appointment related to swelling at the dialysis site. Despite this order, the resident was given breakfast, resulting in the medical appointment being rescheduled. Interviews with nursing staff confirmed that there was a lack of communication between nursing and dietary staff regarding the NPO order, which led to the resident not being properly prepared for the appointment. Additionally, the facility did not ensure that the Pre and Post Dialysis Assessment forms were fully completed for the resident on two separate dates. The required Dialysis Unit Assessment sections were left incomplete, and staff acknowledged that these forms should have been completed, either by the dialysis center or through follow-up by facility staff. The facility's policies required these assessments and documentation to be maintained in the resident's medical record, but this was not done as required.