Failure to Monitor and Communicate Dialysis Care for a Resident
Penalty
Summary
The facility failed to ensure proper communication and collaboration with the outpatient dialysis center and did not consistently monitor the dialysis access site for a resident with end stage renal disease who required hemodialysis. The resident was admitted with a diagnosis of end stage renal disease and was documented as cognitively intact and dependent with mobility. Physician orders required that the resident's dialysis access site be checked for thrill and bruit, as well as for signs and symptoms of infection, every day and night shift. However, the Treatment Administration Record (TAR) for the specified month showed that these checks were not documented as completed on multiple days. Additionally, the facility's policy required that the dialysis site be checked every shift and that a Dialysis Communication form be completed and sent with the resident for each treatment, with documentation reviewed upon the resident's return. Interviews with the Assistant Director of Nursing and the Administrator confirmed that there was no additional documentation to show that the required monitoring and communication had occurred. The lack of documentation and communication represents a failure to follow physician orders and facility policy for dialysis care.