Failure to Document Dialysis Orders and Care Details in EMR
Penalty
Summary
The facility failed to ensure that a resident with end-stage renal disease (ESRD) who was dependent on dialysis had a physician's order for dialysis documented in the Electronic Medical Record (EMR). The resident's care plan noted the presence of a shunt for dialysis, instructions to monitor for infection and bleeding, and restrictions on blood pressure measurement in the affected arm. However, the care plan did not include the dialysis center's location, contact information, or the specific days of dialysis treatment. Additionally, the physician's order for dialysis was missing from the resident's EMR orders tab, although pre- and post-dialysis vital signs and communication forms were present in a separate section of the EMR. Staff interviews revealed that information about which residents were on dialysis was typically communicated verbally, and there was no dedicated dialysis book for the resident. A licensed nurse confirmed that the dialysis order should have been present on the Medication Administration Record (MAR) or Treatment Administration Record (TAR), but it was not. The administrative nurse acknowledged that the omission of the dialysis order was an oversight following the resident's return from the hospital. The facility's policy required coordination and documentation of dialysis care, but these requirements were not fully met in this case.