Failure to Ensure Consistent Dialysis Care Coordination and Documentation
Penalty
Summary
The facility failed to ensure ongoing and consistent collaboration with the dialysis center for a resident requiring dialysis services. The resident, who had severe kidney disease and a hypertensive emergency, was admitted with physician orders for Clonidine transdermal patches to manage hypertension. The dialysis communication binder for this resident did not contain the current physician's orders or a medication list, despite a request from the dialysis center. Additionally, there was no follow-up on the dialysis center's recommendation to discontinue the Clonidine patches, and the medication continued to be administered. Facility staff also documented inconsistent assessments of the resident's dialysis access site. While the resident had a left chest permacatheter, records incorrectly noted the access site as the right upper arm with findings (bruit and thrill) that would not be present with a permacatheter. The resident confirmed the location of her access site and the ongoing use of Clonidine patches, and staff acknowledged the absence of required documentation and communication in the dialysis binder. These lapses were contrary to the facility's policy, which required regular written communication and collaboration with the dialysis provider and attending physician.