Failure to Clarify Physician Orders for Dialysis Medication Administration
Penalty
Summary
The facility failed to ensure that physician's orders regarding medication administration for two residents with end-stage renal disease (ESRD) receiving hemodialysis were properly clarified. Both residents had physician's orders indicating that medications could be administered either prior to dialysis or upon return from dialysis, but there was no documented evidence that the facility contacted the residents' physicians to clarify which specific medications should be given at each time. This lack of clarification was identified through review of clinical records, the Pennsylvania Nurse Practice Act, and staff interviews. One resident was noted to be cognitively intact and required staff assistance for daily care, while the other was able to understand and be understood by others. Both residents had scheduled dialysis sessions multiple times per week. Despite the presence of multiple, potentially conflicting orders regarding medication timing on dialysis days, the facility did not document any communication with the physicians to resolve these ambiguities. The Director of Nursing confirmed that no such clarification was obtained or documented for either resident.