Failure to Consistently Document and Communicate Dialysis Care
Penalty
Summary
The facility failed to ensure that a resident requiring dialysis received care and services consistent with professional standards and the facility's own policy. Specifically, nursing staff did not consistently complete, review, or log dialysis communication sheets for a resident between early April and late July. The facility's policy required staff to document pre- and post-dialysis information, including vital signs and continuity of care notes, in a communication book that should accompany the resident to and from dialysis. However, during the survey, the communication book could not be located, and only a few dates were documented in the log, despite evidence in the electronic medical record that the resident had attended additional dialysis sessions for which no communication documentation was available. The resident involved had diagnoses of end stage renal disease, essential hypertension, and adjustment disorder, and was cognitively intact. The care plan specified regular dialysis sessions and required monitoring and communication with the dialysis center. Interviews with nursing staff and the DON revealed uncertainty about the location of the communication book and inconsistent documentation practices. Requests for additional documentation covering a broader date range were not fulfilled, and the missing records were not located in the electronic medical record as expected. This lack of consistent documentation and communication failed to meet the facility's policy and professional standards for dialysis care.