Failure to Ensure Communication and Post-Dialysis Assessment for Dialysis Resident
Penalty
Summary
The facility failed to maintain adequate communication with the dialysis center and did not ensure completion of required post-dialysis assessments for a resident receiving hemodialysis. The resident, who had multiple diagnoses including end stage renal disease, was scheduled for hemodialysis three times weekly at a community-based dialysis center. The care plan and physician orders required pre- and post-dialysis evaluations, and the facility's policy specified that a Hemodialysis Communication Form should be sent with the resident and returned with documentation from the dialysis center. However, the only documented communication from the dialysis center was a single laboratory report, and staff confirmed that the dialysis center did not return completed forms and that follow-up for treatment reports was not documented. Additionally, there was no evidence in the medical record of pre- or post-dialysis assessments being completed for at least one treatment date, and staff interviews confirmed the absence of these assessments and any related nursing notes. The resident reported that papers were not always sent with him to dialysis and that the dialysis center never sent papers back. The facility's policy required staff to review notes from the dialysis service and to call the center if notes were absent, but this process was not followed, resulting in a lack of documented communication and assessment for the resident's dialysis care.