Failure to Accurately Document Facility Assessment for Dialysis Care
Penalty
Summary
The facility failed to conduct and document a comprehensive facility-wide assessment to determine the necessary resources for competent resident care during both routine operations and emergencies. Specifically, the assessment did not accurately reflect the presence of a resident receiving dialysis, as it listed zero residents requiring this special treatment. This omission was identified during a review of the facility assessment, which had not been updated to include the dialysis patient, despite the resident's ongoing need for dialysis services. A male resident with chronic kidney disease, malignant neoplasm of the kidney, diabetes, and high blood pressure was admitted to the facility and required dialysis three times a week. Documentation confirmed the resident's cognitive intactness and dependence on staff for multiple activities of daily living. The administrator acknowledged the oversight during an interview, stating that the dialysis patient should have been included in the facility assessment. Additionally, the Director of Nursing confirmed that the facility did not have a policy for conducting facility assessments.