Failure to Ensure Proper Communication and Documentation for Dialysis Care
Penalty
Summary
The facility failed to ensure that a resident requiring dialysis received care and services in accordance with facility policy and established protocols. The facility's policy required communication between the facility and the dialysis center, including sending a binder with the resident to each dialysis session and receiving a report upon the resident's return that included pre- and post-weights, vital signs, and other pertinent information. Review of the resident's medical record revealed missing documentation of daily weights on several dates, and there was no indication that these weights were communicated to the dialysis center as required. Additionally, the care plan for the resident did not specify dialysis days, times, or transportation arrangements. Interviews with staff confirmed that while a binder was sent with the resident to dialysis, the dialysis center did not consistently provide the required communication sheets with pre- and post-weights and other relevant information. The Director of Nursing acknowledged that the care plan should have included the resident's dialysis schedule and that the dialysis center was expected to communicate essential information after each session. The deficiency was identified through record review and staff and resident interviews, which demonstrated lapses in communication and documentation related to the resident's dialysis care.