Failure to Communicate Resident Status to Dialysis Center
Penalty
Summary
The facility failed to ensure appropriate communication and documentation with the dialysis (hemolytic) treatment center for a resident with end stage renal disease, diabetes, hypertension, and a history of cerebral infarction. The resident required regular dialysis treatments and had a care plan in place that specified the need for communication with the dialysis center regarding medications, treatments, and coordination of care. However, a review of records from November 2024 through June 2025 revealed a lack of documentation from the dialysis center and no evidence that facility staff had communicated essential information such as diagnoses, current medications, dietary needs, assistance required for activities of daily living, fluid needs, or changes in condition. On one occasion, the resident experienced a significant change in condition, including chest pain, administration of nitroglycerin, and a drop in blood pressure. Despite these changes, the nurse on the following shift did not recheck vital signs or inform the dialysis center of the resident's unstable condition before sending the resident for treatment. Upon arrival at the dialysis center, the resident was noted to be lethargic, short of breath, and hypotensive, prompting the dialysis center to administer treatment at a minimal level and monitor the resident closely. After returning from dialysis, the resident remained unstable and was sent to the emergency department. Interviews with facility staff and the dialysis center nurse confirmed that there was no communication from the facility regarding the resident's change in condition. The facility's own communication tool and policy required that information about recent medications, signs of infection, and changes in condition be shared with the dialysis center, but this was not done. The Director of Nursing acknowledged that required documentation and communication had not been completed since the resident's admission.