Failure to Maintain Physician Orders for Dialysis Treatments
Penalty
Summary
The facility failed to maintain current physician orders for dialysis treatments for two residents who were dependent on renal dialysis and diagnosed with end stage renal disease. For one resident, the medical diagnosis sheet listed dependence on renal dialysis and end stage renal disease, but the physician's order sheet did not include any dialysis treatment orders. Staff interviews confirmed that the resident was receiving dialysis five times a week, yet the necessary orders were missing from the documentation. The regional quality assurance staff acknowledged that the dialysis order had likely been omitted from the physician's order sheet. Similarly, another resident with diagnoses of end stage renal disease, stage 4 chronic kidney disease, and dependence on renal dialysis did not have dialysis treatment orders documented from the time of readmission until a later date. This resident also confirmed receiving dialysis treatments in the facility, and a licensed practical nurse verified the absence of dialysis treatment orders. The facility's own records and agreements indicated that the LTC facility is responsible for the development and implementation of each dialysis resident's overall plan of care, including coordination of dialysis access orders, but failed to ensure that current orders were in place for these residents.