Failure to Maintain Dialysis Communication and Vendor Contracts
Penalty
Summary
The facility failed to ensure consistent communication and documentation regarding dialysis care for two of three residents requiring such services. Specifically, for one resident with diagnoses including high blood pressure, anemia, and renal insufficiency, dialysis communication forms were either missing or incomplete for several months, as confirmed by staff review. Another resident with high blood pressure, diabetes, and end-stage renal disease also had incomplete or missing dialysis communication forms, with staff acknowledging that the documentation process had only recently been initiated. These lapses were identified through review of clinical records and staff interviews, which confirmed the absence and incompleteness of required documentation. Additionally, the facility did not maintain current dialysis contracts with the dialysis vendors for two residents as required by facility policy. Review of facility-provided dialysis agreements revealed that contracts were missing for these residents, a fact confirmed by the Nursing Home Administrator. The lack of proper agreements and incomplete communication forms were in violation of facility policy and state regulations regarding clinical records and nursing services.