Failure to Ensure Proper Communication and Documentation for Dialysis Care
Penalty
Summary
The facility failed to ensure that a resident requiring dialysis received care and services consistent with professional standards of practice, specifically regarding communication with the dialysis center and documentation of vital signs. The resident, who had severe cognitive impairment and diagnoses including end stage renal disease and chronic obstructive pulmonary disease, was scheduled for dialysis three times a week. The care plan indicated the need for dialysis and included a fluid restriction, but the clinical record did not document the fluid restriction or any communication with the physician about it. Review of the resident's dialysis notebook revealed multiple gaps in documentation of pre- and post-dialysis vital signs over several weeks. The facility's policy required collection of dialysis run sheets and follow-up with the provider on recommendations, but these records were missing for numerous dialysis sessions. Staff interviews confirmed the absence of required documentation, and the corporate nurse was unable to locate the missing vital sign records.