Failure to Update Physician Orders for Dialysis in Medical Records
Penalty
Summary
The facility failed to ensure that medical records were complete and accurately documented for a resident with end stage renal disease and dependence on renal dialysis. The resident was originally ordered to receive dialysis two times per week, but a progress note indicated that the dialysis center increased the frequency to three times per week. Despite this change, the physician's orders in the electronic health record were not updated to reflect the new dialysis schedule. Interviews with the resident, a nurse, and the MDS Coordinator confirmed that the resident was receiving dialysis three times weekly, and the MDS Coordinator had obtained records from the dialysis center verifying this schedule. However, the physician's orders remained outdated in the facility's records. Further interviews revealed that both the MDS Coordinator and the Director of Nursing were unaware of why the electronic health records had not been updated to match the new dialysis regimen. The Director of Nursing stated that it was the responsibility of the nursing staff to update physician orders when there is a change in care or treatment. The facility's policy required review and confirmation of physician orders for dialysis, but this procedure was not followed, resulting in incomplete and inaccurate documentation in the resident's medical record.