Failure to Maintain Dialysis Communication Documentation
Penalty
Summary
The facility failed to maintain completed dialysis communication forms for three residents who required offsite dialysis services. For each of these residents, the clinical records lacked documented evidence of completed dialysis communication transfer forms for multiple dates when the residents attended dialysis treatments. The absence of these forms was confirmed by the Director of Nursing (DON) and the Regional Clinical Director (RDC), who acknowledged that the forms were either missing or not consistently placed in the residents' hard charts or electronic health records. One resident's order summary report did not include an order for renal dialysis or for care and assessment of the access port site, which meant that necessary assessments would not be entered onto the Treatment Administration Record (TAR) and would not alert nursing staff to perform or document these assessments. The DON confirmed that without these orders, the required assessments would not be completed or documented. Additionally, the facility's policy required ongoing communication and coordination between the facility and the dialysis center, including the initiation and maintenance of pre/post dialysis communication forms, which was not consistently followed. Interviews with nursing staff and review of facility policy further revealed that the expectation was for nursing staff to complete the communication form before transport to dialysis and upon the resident's return, and to ensure the form was returned and filed appropriately. The lack of completed and maintained communication forms was acknowledged by facility leadership, who confirmed that the available documentation was incomplete and not inclusive of all required communication for the residents' dialysis treatments.