Failure to Ensure Consistent Pre- and Post-Dialysis Communication and Assessment
Penalty
Summary
The facility failed to consistently communicate a resident's medical condition through pre- and post-dialysis communication prior to and after hemodialysis sessions. The resident in question had multiple complex medical diagnoses, including end-stage renal disease requiring hemodialysis, hypertension, diabetes mellitus, chronic obstructive pulmonary disease, peripheral vascular disease, and a recent cervical spine fracture requiring a neck collar. The care plan required daily assessment of the arteriovenous (AV) fistula and completion of dialysis communication forms before and after each dialysis session. However, review of the electronic medical record revealed missing documentation of pre- and post-dialysis assessments and communication forms on several specified dates. Interviews with nursing staff and administration confirmed that the process for handling dialysis communication sheets was not consistently followed. Staff reported that completed forms were to be placed in a binder and scanned into the resident's chart, and if missing, the dialysis center was to be contacted for a report. Administrative staff acknowledged ongoing issues with obtaining completed communication sheets from the dialysis center and had attempted to address this by sending the forms in a binder. Despite these procedures, the required documentation was not consistently present, resulting in a failure to ensure proper communication and assessment related to the resident's dialysis care.