Failure to Communicate Significant Changes to Dialysis Center
Penalty
Summary
The facility failed to ensure appropriate communication and coordination of care for a resident requiring dialysis services. The resident, who had diagnoses including end stage renal disease and failure to thrive, experienced a significant weight loss of 6.25% (9.7 pounds) in one month and had an unwitnessed fall. Despite these significant changes in condition, there was no evidence in the communication binder, communication sheets, or medical record that these events were communicated to the dialysis center, as required by facility policy. The policy specifically states that any change of condition, including weight changes and falls, must be documented and communicated prior to dialysis treatment. Staff at the dialysis center reported that they had been attempting to contact the facility for three weeks regarding the resident's weight loss, and noted severe malnutrition and muscle wasting that had worsened since the last treatment. The communication sheets reviewed for the relevant months only indicated "routine dialysis" and did not include information about the resident's weight loss or fall. The Director of Nursing Services confirmed that there was no documentation of these communications, indicating a failure to follow established protocols for sharing critical health information with the dialysis provider.