Failure to Maintain Complete Medical Records for Dialysis Resident
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident when the resident's Dialysis Communication Records binder went missing. The resident, who had diagnoses including acute respiratory failure, end stage renal disease, and was dependent on renal dialysis, was admitted and later readmitted to the facility. The resident required substantial to maximal assistance with daily activities and had a scheduled dialysis regimen. On a specified date, the resident was transferred from the dialysis center to a general acute care hospital due to altered mental status and did not return to the facility, resulting in the facility not receiving the Dialysis Communication binder back. Interviews with facility staff revealed that the binder, which is used to document and communicate care between the facility and the dialysis center, was not retrieved after the resident's transfer. The Director of Nursing confirmed that nurses are responsible for ensuring the binder accompanies the resident and is returned, but in this case, the binder was not recovered and staff did not communicate with the dialysis center to retrieve it. The facility's policy requires that documentation in the medical record be objective, complete, and accurate, but the missing binder resulted in incomplete records for the resident.