Failure to Ensure Ongoing Communication and Documentation for Dialysis Care
Penalty
Summary
The facility failed to ensure ongoing communication and collaboration with the dialysis center for two residents diagnosed with end stage renal disease, diabetes, and either hypertension or hypotension, who had physician orders for dialysis three times per week. For both residents, multiple entries in the dialysis communication book were missing critical information from the dialysis center, including vital signs, weights, run times, dry weights, post-dialysis assessments, information on complications, medications administered, and whether labs were drawn. In some instances, the forms referenced attachments for medication details, but no such attachments or dosage information were present. There was no documentation in either resident's medical record indicating that the facility made further attempts to obtain the missing information from the dialysis center. During an interview, the Assistant Director of Nursing acknowledged the importance of this communication for monitoring complications and ensuring proper follow-up care, and stated that the expectation was to call the dialysis center to obtain the necessary information and document it accordingly. The facility's policy required collaboration with the dialysis provider and monitoring of residents before, during, and after dialysis treatments, but this was not followed as evidenced by the missing documentation and lack of follow-up.