Failure to Ensure Consistent Communication and Documentation for Dialysis Care
Penalty
Summary
The facility failed to ensure consistent and effective communication and collaboration with the dialysis center for a resident requiring dialysis services. The resident, who had end stage renal disease and was cognitively intact, did not consistently have pre-assessment forms completed by the facility prior to dialysis appointments, with several dates missing documentation. Additionally, the facility did not reliably send paperwork with the resident to the dialysis center, and the dialysis center did not consistently send communication back with the resident after treatments. Interviews with staff revealed uncertainty about what paperwork was being sent or received, and documentation from the dialysis center was rarely uploaded into the resident's medical record. Further investigation showed that the only communication sheet from the dialysis center uploaded into the medical record was from a single date, despite multiple treatments occurring during the review period. Staff interviews confirmed that communication forms from the dialysis center were rarely received, and when not received, staff often assumed there were no changes in the resident's condition. The facility's policy required comprehensive monitoring and exchange of information with the dialysis center, but this was not consistently followed, resulting in a lack of person-centered care and failure to meet professional standards of practice for dialysis services.