Failure to Follow Hemodialysis Communication and Assessment Policy
Penalty
Summary
The facility failed to follow its own policy regarding the care and monitoring of residents receiving dialysis. According to the facility's Hemodialysis Care policy, staff are required to conduct and document a pre-dialysis assessment using a dialysis communication tool, print it, and send it with the resident to the dialysis center. After dialysis, staff are expected to receive a report from the dialysis provider and/or review the documentation provided, and promptly contact the dialysis center with any questions or concerns. For one resident with end-stage renal disease who was cognitively intact and required assistance with daily care, there was no evidence in the clinical record or at the nursing station that these assessments or communications were being completed or shared as required. An interview with the DON confirmed that there was no documented evidence of pre-dialysis assessments being sent with the resident or of post-dialysis information being received and reviewed by staff, as outlined in the facility's policy. This deficiency was identified through review of policies, clinical records, observations, and staff interviews.