Failure to Notify Physician of Missed Dialysis Leading to Hospitalization
Penalty
Summary
A deficiency occurred when the facility failed to notify a physician regarding a resident who did not receive dialysis for 12 days, resulting in the resident's hospitalization. The resident had multiple diagnoses, including end-stage renal disease and dependence on renal dialysis, but the Physician Order Sheet did not include an order for dialysis, only for monitoring the dialysis catheter. The care plan also did not document that the resident was receiving or awaiting approval for dialysis treatments. Progress notes indicated that the resident complained of symptoms such as shortness of breath, weakness, and sweating, and reported missing a dialysis session. Although the physician was notified of a missed dialysis day and low glucose, there was no documentation that the physician was informed about the ongoing lack of dialysis treatments or that the resident went 12 days without dialysis. The medical director confirmed that he was not made aware that the resident had not received dialysis as recommended and stated that, had he known, he would have sent the resident to the hospital for treatment. Hospital records confirmed that the resident had not received dialysis for about two weeks since transfer to the facility, resulting in elevated potassium, BUN, and creatinine levels. The hospital provided dialysis, and the resident was hospitalized for five days before being discharged back to the facility. The facility's policy requires timely notification of the physician and family when there is a significant change in a resident's condition or a need to alter treatment. In this case, the lack of communication and documentation regarding the resident's dialysis needs and missed treatments led to a significant lapse in care and a failure to follow established protocols for physician notification.