Incomplete Dialysis Communication Documentation for Two Residents
Penalty
Summary
The facility failed to ensure that dialysis communication records were fully completed for two residents who required dialysis services. According to the facility's contract and policy, staff are responsible for maintaining complete records and ensuring ongoing communication and coordination with dialysis providers. For both residents, who had significant medical histories including end-stage renal disease, diabetes, and other chronic conditions, the PRE/POST DIALYSIS COMMUNICATION forms were found to be incomplete on multiple occasions. Missing documentation included vital information such as pre- and post-dialysis weights, vital signs, changes at the dialysis access site, and staff signatures. Medical record reviews showed that these documentation lapses occurred repeatedly over the course of a month for both residents, despite facility policies requiring thorough completion of these forms. During an interview, the DON confirmed that the forms were not completed in their entirety as required. The incomplete records were directly observed in the residents' files, and the deficiency was acknowledged by facility leadership.