Incomplete Documentation and Communication for Dialysis Care
Penalty
Summary
The facility failed to ensure complete and documented communication between facility nursing staff and the dialysis care provider for two residents receiving dialysis services. According to facility policy and a long-term care agreement with the dialysis provider, communication regarding residents' health status, including vital signs, lab results, medication changes, and signs or symptoms of infection, must be consistently documented and shared using a dialysis communication binder. However, review of the communication binders for two residents revealed multiple instances where required information was missing on several dates. The communication sheets, which are divided into sections for both facility and dialysis staff to complete before, during, and after treatment, were found to be incomplete, lacking vital information such as vital signs, assessment of the dialysis access site, and documentation of infection symptoms. Interviews with facility and dialysis staff confirmed that, at times, information was communicated verbally rather than documented as required by protocol. One nurse stated that facility staff sometimes call the dialysis nurse to relay information but do not document these communications. The dialysis nurse also indicated that while the communication binder is reviewed prior to treatment, verbal communication is sometimes used for irregular concerns. These practices resulted in incomplete records and a lack of documented communication as required by facility policy and the agreement with the dialysis provider.