Incomplete Dialysis Communication Documentation for Resident
Penalty
Summary
The facility failed to ensure that a resident requiring dialysis received services consistent with professional standards, the care plan, and the resident's preferences. Specifically, the dialysis communication forms for the resident were not completed with the necessary treatment information on multiple occasions. On the dates reviewed, only the pre-dialysis information was filled out, while the sections for dialysis treatment information were either left blank or marked as not applicable. The resident in question was an older female with moderate cognitive impairment and multiple active diagnoses, including renal insufficiency, renal failure or end-stage renal disease, heart failure, and respiratory failure. She was admitted to the facility and had physician's orders and a care plan indicating the need for regular dialysis. The process required the completion of pre- and post-dialysis sections on a communication form, with the expectation that the dialysis center would fill out the treatment information and return the form with the resident. Interviews with nursing staff revealed that the pre-dialysis section was completed by the morning nurse, and the afternoon nurse was responsible for ensuring the post-dialysis information was recorded. However, the dialysis center often did not return the completed forms, and the afternoon nurse sometimes had difficulty obtaining the necessary information. The ADON, responsible for oversight, was unaware that the forms were incomplete, and the facility's policy required all sections of the communication record to be completed and filed.