Incomplete Dialysis Communication Documentation
Penalty
Summary
The facility failed to ensure that a resident requiring dialysis received services consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. Specifically, the Dialysis Hand Off Communication Report forms, which are intended to facilitate ongoing communication between the facility and the dialysis center, were either not completed or were incomplete for 22 out of 23 opportunities. Record review showed that for the months reviewed, there were no report forms accounted for in May and only five out of nine forms in July, with only one of those being fully completed. The process required the charge nurse to complete the top portion of the form before sending the resident to dialysis, and the dialysis center to complete the bottom portion upon return, but this process was not consistently followed. The resident involved was a female with multiple diagnoses, including end-stage renal disease, diabetes with neuropathy, heart failure, and atrial fibrillation. She was cognitively intact and required assistance with activities of daily living. Her care plan and physician orders specified regular dialysis sessions and the need for pre- and post-dialysis vital signs. Despite these orders and the facility's policy requiring the use of the Dialysis Communication Form, the forms were not properly completed or maintained in the resident's medical record as required. The interim DON confirmed the process and acknowledged that it was the unit manager's responsibility to ensure compliance, but this was not consistently done.