Failure to Ensure Communication and Coordination for Dialysis Care
Penalty
Summary
The facility failed to ensure effective communication and coordination between the facility and the dialysis provider for a resident with end stage renal disease who required regular dialysis treatments. According to the facility's own policy, the resident's care plan should reflect dialysis needs and there should be ongoing communication between the dialysis clinic and the facility. However, for approximately two months, there was no written or verbal communication between the facility and the dialysis provider regarding the resident's dialysis treatments. The dialysis clinic nurse confirmed that the facility had not provided a form for reporting, nor had they called to obtain verbal updates. Similarly, facility staff acknowledged that written communication from the dialysis clinic had ceased for at least four weeks, and no efforts were made to reestablish this communication or request reports from the dialysis provider. The resident, who had diagnoses of end stage renal disease and dependence on renal dialysis, reported that while facility nurses initially placed a form with vital signs and weight in a bag on the wheelchair, dialysis nurses stopped retrieving the form and the resident eventually stopped reminding them. The resident also stated that no information was provided back to the facility after dialysis treatments for a significant period. The Director of Nursing stated that it was expected for licensed nurses to send and receive written reports for each dialysis appointment, but this process was not followed, resulting in a lack of coordinated and consistent care for the resident.