Failure to Document Dialysis Communication and Administer Medications as Ordered
Penalty
Summary
The facility failed to maintain complete and accurate records of dialysis communication and did not ensure that medications were administered according to physician's orders for a resident receiving dialysis. A review of the Memorandum of Agreement between the facility and the dialysis provider required the exchange of relevant information regarding the resident's condition and treatment, and facility policy mandated documentation of dialysis care in the medical record. However, the clinical record for a resident with diagnoses including diabetes, end stage renal disease, and respiratory failure lacked evidence of completed dialysis communication forms for multiple scheduled dialysis treatments. Additionally, the resident's care plan included an intervention to ensure medication administration times did not conflict with the dialysis schedule. Despite this, the Medication Administration Records showed that several prescribed medications were not administered on dialysis days, with the reason documented as Leave of Absence. There was no documentation that the physician was notified about the missed or altered medication administration times on these days. Interviews with facility leadership confirmed the absence of required dialysis communication documentation and the failure to administer medications as ordered, as well as the lack of physician notification regarding these omissions. These findings were cited under multiple state regulations related to licensee responsibility, management, medical records, and nursing services.