Failure to Document Pre- and Post-Dialysis Assessments and Communication
Penalty
Summary
The facility failed to provide required pre- and post-dialysis communication documentation for one resident who was dependent on renal dialysis. According to the facility's policy, staff were to complete a Pre/Post Dialysis Communication Form for each dialysis session, which included pre- and post-dialysis assessments, medication checks, and documentation of meals sent with the resident. The form was to be sent with the resident to the dialysis center and returned to the facility for inclusion in the medical record. Review of the resident's records revealed that for eight dialysis treatments over a specified period, there was no evidence in either the hard copy chart or the electronic medical record that the required forms or assessments were completed or maintained. Interviews with staff, including RNs, LPNs, medical records personnel, the DON, and the Executive Director, confirmed that the process for completing and tracking the Pre/Post Dialysis Communication Form was not consistently followed. Staff acknowledged the importance of the form for monitoring the resident's condition but indicated that forms were often not completed, not returned from the dialysis center, or not properly filed. The resident involved was cognitively intact and had a history of diabetes, chronic kidney disease stage 5, and dependence on hemodialysis. Despite the facility's policy and care plan requirements, the necessary documentation and assessments were not performed or recorded for the resident's dialysis treatments.