Incomplete Dialysis Communication Documentation
Penalty
Summary
The facility failed to maintain complete and accurate dialysis communication records for a resident who required hemodialysis. Review of the facility's policy indicated that nurses are responsible for educating residents and families about dialysis risks and for ensuring regular communication between the facility and the dialysis center, especially when there are changes in the resident's condition. For the resident in question, record review showed multiple deficiencies in the documentation of Dialysis Communication Sheets (DCS) over several dates, including incomplete forms, missing resident and dialysis center names, and undated records. Additionally, there were no corresponding progress notes in the resident's clinical record for the dates when dialysis was provided. The resident had a history of end stage renal disease and was dependent on renal dialysis, with a scheduled regimen of dialysis three times per week. Interviews with staff confirmed that the process involved sending a communication form with the resident to the dialysis center, which was to be completed and returned, with vital signs entered into the electronic medical record and the form filed in a dialysis book. However, the review found that this process was not consistently followed, resulting in incomplete documentation and lack of required communication records for the resident's dialysis care.