Failure to Document and Communicate Dialysis Assessments
Penalty
Summary
The facility failed to ensure proper assessment and ongoing communication with the contracted dialysis agency for a resident requiring dialysis services. According to the facility's agreement with the dialysis agency, healthcare staff are required to assess each patient's physical condition and determine stability prior to every transfer for outpatient hemodialysis, with this assessment and communication documented on a dialysis communication form. For one resident with end stage renal disease and dependence on renal dialysis, there was no documented evidence of completed dialysis communication forms for two specific dates following the resident's re-admission. Interviews with facility staff, including an LPN, the Assistant Director of Nursing, and the Director of Nursing, confirmed that the dialysis communication forms were not present in the facility's records for the identified dates. Staff acknowledged that these forms are the established method for communication between the facility and the dialysis agency, and that they should have been completed and included in the resident's electronic health record for each dialysis session.