Incomplete Dialysis Communication Documentation for Two Residents
Penalty
Summary
The facility failed to ensure that the Dialysis Communication Forms were properly completed for two residents receiving hemodialysis. For both residents, licensed staff did not document required pre- and post-dialysis information, including the status of dialysis access sites and the general condition of the residents upon return from the dialysis center. Medical record reviews showed multiple instances where sections of the Dialysis Communication Forms were left blank, such as shunt location/status, medications administered prior to dialysis, catheter status, and general condition post-dialysis. These omissions were in direct contradiction to the facility's own policies and procedures, which require thorough monitoring and documentation before and after dialysis treatments. Both residents had physician orders for regular hemodialysis and specific instructions to monitor their access sites every shift. Despite these orders, the required documentation was not completed on several dates. During interviews, both the RN and DON acknowledged the importance of conducting and documenting pre- and post-dialysis assessments to ensure appropriate care and timely interventions. The lack of completed documentation meant that the medical records for these residents were incomplete, as confirmed by the facility staff.