Failure to Notify Physician of Missed Dialysis Treatments
Penalty
Summary
The facility failed to notify physicians when residents did not receive their scheduled hemodialysis treatments at the onsite dialysis center. This deficiency was identified for two residents with end-stage renal disease who were dependent on regular dialysis as ordered by their physicians. The facility's policy required care according to recognized standards, which includes physician notification when ordered treatments are missed. For one resident, multiple missed dialysis sessions occurred due to various reasons, including a flood in the dialysis center, inadequate staffing, and an inoperable elevator preventing access to the treatment area. Nursing notes documented the missed treatments but did not show evidence that the physician was notified on any of these occasions. Interviews with facility staff confirmed the lack of documentation and physician notification for each missed or rescheduled dialysis session. A second resident also missed scheduled dialysis treatments due to inadequate staffing and the inoperable elevator. Again, there was no evidence in the nursing notes or clinical record that the physician was notified of these missed treatments. Staff interviews corroborated that the required notifications were not made, and the deficiency was cited under relevant state codes for medical records, resident care policies, and nursing services.