Failure to Provide Safe and Appropriate Dialysis Care and Communication
Penalty
Summary
The facility failed to provide safe and appropriate dialysis care for two residents requiring such services, as evidenced by a lack of assessment, monitoring, intervention, and communication with the dialysis center. Facility policy required monitoring of residents' conditions before and after dialysis, documentation of access site status, communication with the dialysis facility, and implementation of physician and dietician orders, including fluid restrictions and vital sign monitoring. However, for both residents, there were multiple instances where these requirements were not met. For one resident with end-stage renal disease and other significant diagnoses, the facility did not consistently monitor or document vital signs before and after dialysis, with several missed opportunities noted across multiple months. Communication forms between the facility and the dialysis center were incomplete or missing, and staff were unable to locate the dialysis communication book or provide additional documentation. Orders regarding monitoring the dialysis access site and sending communication sheets with the resident were not reliably followed. For the second resident, the facility did not document the implementation of a recommended fluid restriction, nor did it provide evidence of access site monitoring for several months. There was no documentation of communication with the dialysis clinic, and the dialysis clinic confirmed that pre-weights and communication sheets were not received. Interviews with facility staff, including the dietician and DON, confirmed that recommendations and required assessments were not implemented or communicated as per policy, and that the facility's procedures were not followed.