Failure to Maintain Dialysis Communication Documentation
Penalty
Summary
The facility failed to ensure that dialysis communication forms were consistently utilized and maintained for a resident dependent on dialysis. Review of the resident's medical record revealed multiple missing dialysis communication forms for several dates across three months. The facility's policy required that upon return from dialysis, the nurse review the communication form sent to the dialysis center, and if the form was not provided, staff should document this. However, interviews with nursing staff and the DON confirmed that some forms were missing and that the dialysis center did not always send the forms back with the resident. Staff indicated that the dialysis center would call if there were any changes, but the required documentation was not consistently present in the resident's chart. The resident involved had complex medical needs, including end stage renal disease, diabetes mellitus type 2, severe calorie malnutrition, and dependence on dialysis, among other diagnoses. The care plan for this resident included interventions to check for new orders upon return from dialysis and to coordinate care with the dialysis center. Despite these interventions, the absence of required communication forms indicated a lapse in following facility policy and ensuring proper documentation and communication regarding the resident's dialysis care.