Failure to Notify Physician of Missed Dialysis Treatment
Penalty
Summary
The facility failed to notify the attending physician when a resident with end stage renal disease missed a scheduled dialysis treatment. The resident was scheduled for hemodialysis three times a week, and on one occasion, did not attend the treatment because transportation did not arrive. Review of the resident's clinical records confirmed the missed dialysis session, and interviews with nursing staff and the Director of Nursing revealed that the attending physician was not informed of the missed treatment, despite facility practice and policy requiring such notification. Interviews with multiple staff members, including two LVNs and an RN, confirmed that it was standard practice to notify the attending physician of any missed dialysis treatments. However, documentation and staff statements indicated that this notification did not occur. The facility's policy on changes in a resident's condition or status specifically required physician notification in the event of significant changes, such as missed treatments, but this protocol was not followed in this instance.