Failure to Ensure Proper Dialysis Communication and Documentation
Penalty
Summary
The facility failed to ensure that a resident requiring dialysis received care and services consistent with professional standards of practice. The resident, admitted with end stage renal disease and dependent on renal dialysis, had physician orders to receive dialysis three times a week at an external provider. Review of the facility's dialysis communication sheets revealed multiple instances where required pre-dialysis information was missing, including documentation of meal provision, medication administration, and condition alerts. Several forms were also not signed by facility staff, and on some dates, the forms were missing entirely. Interviews with the Director of Nursing and an LPN confirmed the missing information and incomplete forms. The LPN explained that the forms should include vital signs, meal status, and the resident's condition, and that the forms serve as the primary means of communication with the dialysis provider. The Director of Nursing acknowledged that the facility's protocol required these forms to be completed and signed by nursing staff, which was not consistently done for the resident in question.