Failure to Coordinate Dialysis Care and Document Required Weights
Penalty
Summary
Facility staff failed to coordinate care with the dialysis center for a resident diagnosed with end stage renal disease who required dialysis three times a week. The resident's care plan included interventions to coordinate care with the dialysis provider as needed, and facility policy required obtaining pre- and post-dialysis weights and ensuring communication with the dialysis center. However, during clinical record review, there was no documentation of pre- or post-dialysis weights for the resident, and the dialysis book intended to accompany the resident to dialysis contained only blank pages. Interviews with staff revealed that required paperwork was not consistently sent with the resident to dialysis, and staff did not obtain or document the necessary weights as outlined in facility policy. The absence of completed documentation and lack of coordination with the dialysis center were confirmed by both the Assistant Director of Nursing and the Unit Manager. No further information or documentation regarding the coordination of care was provided to the survey team prior to the exit conference.