Failure to Establish and Implement Dialysis Care Policies and Monitoring
Penalty
Summary
The facility failed to provide safe and appropriate dialysis care and services for a resident requiring dialysis. There were no facility policies in place for dialysis care and management, dialysis transportation, or communication with the dialysis center. The facility also lacked a contract with the dialysis provider. Staff interviews revealed that the resident's electronic chart did not contain dialysis orders, schedules, or monitoring instructions, and staff were unaware of any communication or monitoring protocols related to the resident's dialysis care. The only documentation available was a care plan entry noting dialysis and a form for ambulance transport, with no evidence of pre- or post-dialysis monitoring by facility staff. The resident, who had a dialysis port and required regular treatments, reported that transportation was arranged prior to admission and that he did not receive meals from the facility for dialysis days. Staff confirmed that dialysis assessments and weights were performed at the dialysis center, but no information was sent back to the facility. Review of the resident's records showed only an admission weight and no ongoing monitoring or physician orders related to dialysis. The facility was unable to provide requested documentation for dialysis monitoring, relevant policies, or a contract with the dialysis provider during the survey.