Failure to Communicate Change of Condition to Dialysis Center
Penalty
Summary
The facility failed to ensure proper communication with the dialysis center regarding a resident who was receiving hemodialysis treatment. The resident, who had diagnoses including end stage renal disease, hemodialysis, and dementia, experienced an episode of confusion that was documented in the facility's records. However, the licensed nursing staff did not communicate this change of condition to the dialysis center staff, nor did they document it in the Dialysis Communication Record, which is intended to facilitate information sharing between facility and dialysis staff. Interviews with facility staff confirmed that changes in a resident's condition, such as the episode of confusion, should be communicated immediately to the dialysis center to ensure appropriate management and continuity of care. The facility's policy also emphasized the importance of structured communication and documentation of any changes in condition. Despite these requirements, the failure to communicate the resident's change of condition represented a lapse in following established protocols for residents receiving dialysis services.