Failure to Maintain Communication and Documentation for Dialysis Services
Penalty
Summary
The facility failed to ensure proper communication, coordination, and collaboration with the dialysis center for two residents who required dialysis services. For one resident with end stage renal disease and a history of traumatic amputation and anemia, multiple Hemodialysis Communication Records were either incomplete, missing, or not signed by facility nurses or dialysis staff. The resident's care plan required monitoring of the dialysis site and communication with the dialysis center, but records showed repeated lapses in documentation and follow-up. Interviews with staff revealed confusion about the process for handling communication records, with some staff admitting to filing incomplete forms and not notifying supervisors when information was missing. Another resident, admitted with severe sepsis, acute kidney failure, and dependence on dialysis, also had deficiencies in the completion of Hemodialysis Communication Records. Several records lacked signatures from either the dialysis facility nurse or the facility nurse, and there was a consistent absence of required identifying information such as the resident's name, ID number, and physician's name. The DON confirmed that the forms were not fully completed because they were stored in a binder labeled with the resident's name and then uploaded into the electronic medical record, rather than being filled out in full as required. Interviews with facility leadership, including the DON and regional nurse, revealed that there was no established policy or process for tracking or auditing the Hemodialysis Communication Records. The DON acknowledged that nobody was consistently auditing the records to ensure completeness, and there was no system in place to ensure that all necessary information was obtained from the dialysis center before filing the records. This lack of process contributed to the ongoing deficiencies in communication and documentation for residents receiving dialysis.