Failure to Document Post-Dialysis Weight for Resident Receiving Hemodialysis
Penalty
Summary
The facility failed to ensure that a post-dialysis assessment was completed for a resident who required hemodialysis. Specifically, the dialysis center did not record the resident's post-dialysis weight on the communication record for a specified date. This omission was verified during record reviews and interviews with both a Licensed Vocational Nurse (LVN) and the Assistant Director of Nurses (ADON), who confirmed that the post-dialysis weight was missing and acknowledged that the nursing staff should have contacted the dialysis center to obtain this information. The resident involved had a diagnosis of end stage renal disease and was dependent on hemodialysis, with a care plan in place that included monitoring weight and reporting significant changes to the physician. The facility's policy required documentation of dialysis treatment in the resident's medical record. Despite these requirements, the absence of the post-dialysis weight was not addressed by the nursing staff, resulting in incomplete documentation of the resident's dialysis care.