Failure to Maintain Consistent Dialysis Communication for Residents
Penalty
Summary
The facility failed to maintain consistent and complete communication regarding dialysis care for two residents who required hemodialysis. According to the facility's Hemodialysis Care Policy, staff are required to document and communicate specific information before and after each dialysis treatment, including vital signs, weights, medication administration, meal and fluid intake, and any additional alerts. This information is to be recorded on the Dialysis Communication Tool and shared between the facility and the dialysis provider. However, a review of the clinical records for two residents with end-stage renal disease and dependence on dialysis revealed multiple instances where dialysis communication forms were either incomplete or missing entirely on several treatment dates. For one resident with diagnoses including end-stage renal disease, intellectual disabilities, and anemia, several dialysis communication forms were found to be incomplete or absent over a period of weeks. Similarly, another resident with a history of right below the knee amputation, hypertension, anemia, and dialysis dependence also had multiple dates where required communication forms were incomplete or missing. The Director of Nursing confirmed that the facility did not ensure consistent dialysis communication for these residents, as required by policy and physician orders.