Failure to Maintain Consistent Dialysis Communication
Penalty
Summary
The facility failed to maintain consistent and complete communication regarding dialysis care for three residents with end stage renal disease who required regular dialysis treatments. According to the facility's own policy, licensed nurses are required to communicate with the dialysis center using a designated communication form or other written/telephonic means, documenting information such as medication administration, treatment orders, laboratory values, vital signs, advanced directives, nutrition/fluid management, treatments provided, adverse reactions, changes in condition, injuries, and transportation concerns. However, review of the clinical records and dialysis communication forms for the three residents revealed multiple instances where these forms were incomplete on several treatment dates. The affected residents had complex medical histories, including diagnoses of end stage renal disease, hypertension, diabetes, heart disease, and bladder cancer, and were scheduled for dialysis at specific times and days each week. Despite these needs, the required communication forms were not fully completed for numerous dialysis sessions, as confirmed by the Director of Nursing. This failure to ensure ongoing and thorough communication with the dialysis center was identified through review of facility policy, clinical records, and staff interviews.