Failure to Complete Pre-Dialysis Assessment and Documentation
Penalty
Summary
The facility failed to properly assess a resident with end stage renal disease and obstructive sleep apnea prior to dialysis treatment. The resident, who was dependent on staff for bed mobility and transfers and had intact cognition, was admitted to the facility and required dialysis services. Review of the dialysis communication form for the resident showed that only the patient's name, date, and pre-dialysis weight were completed, while critical sections such as vital signs, code status, pain assessment, changes in condition, and the staff member's name and title were left blank. The Director of Nursing confirmed that the expectation was for residents to be assessed before going to dialysis and for the communication form to be fully completed, which did not occur in this instance. Facility policy also required communication of daily weights and any changes in condition or mood between the dialysis provider and the facility.