Failure to Notify Physician After Missed Dialysis Session
Penalty
Summary
The facility failed to notify a resident's physician when the resident missed a scheduled dialysis session. The resident, who had diagnoses including end stage renal disease, dependence on dialysis, and other significant medical conditions, was scheduled to receive dialysis three times a week. On the day of the missed session, transportation for the resident was delayed, resulting in the dialysis center being unable to accommodate the resident due to the late arrival. Although the dialysis session was rescheduled for the following day, the physician was not informed of the missed treatment. Documentation showed that the resident was being monitored for signs and symptoms of fluid overload after missing the dialysis session. Interviews with staff, including an LVN and the DON, confirmed that the physician was not notified of the missed session, despite facility policy requiring prompt notification of changes in a resident's condition or status. The staff acknowledged that the physician should have been informed to allow for potential additional orders or interventions.