Failure to Ensure Communication and Implementation of Dialysis Orders
Penalty
Summary
The facility failed to ensure ongoing communication and collaboration with dialysis services for a resident with renal insufficiency, diabetes mellitus, and depression who required dialysis. The resident's care plan lacked specific instructions regarding the management of hypotension, the need for blood pressure monitoring, and contained conflicting information about fluid restrictions. Hospital discharge orders indicated no fluid restriction was needed, but facility physician orders and the care plan included a fluid restriction and a high sodium diet, creating inconsistency in care directives. Additionally, the care plan did not detail how communication with the dialysis center should occur, what information should be shared, or who was responsible for follow-up. Medical records showed that after the dialysis center communicated the need for twice daily blood pressure checks due to the resident's low blood pressure and high ostomy output, the facility failed to consistently implement this order. Blood pressure readings were not documented as required, and there was no evidence that medication orders to increase phosphorus supplementation or to adjust fluid intake were implemented as communicated by the dialysis provider. The resident continued to arrive at dialysis with low blood pressure, and the dialysis center reported difficulty reaching facility staff to relay urgent orders. Interviews revealed that the nurse manager was absent when a critical voicemail was left by the dialysis center regarding new medication orders, and there was no process in place to ensure voicemails were checked in her absence. As a result, the resident did not receive the necessary medications or blood pressure monitoring prior to dialysis, leading to a situation where the resident was sent to dialysis with undetected hypotension and ultimately required transfer to the emergency department. The facility's own hemodialysis policy required ongoing communication and collaboration with the dialysis team, which was not maintained in this case.