Failure to Provide Safe and Appropriate Dialysis Care and Medication Administration
Penalty
Summary
The facility failed to provide necessary care and treatment for residents requiring dialysis, specifically related to pre- and post-dialysis assessments, medication scheduling, and medication administration. For one resident with end stage renal failure, the facility did not complete or retain required pre- and post-dialysis assessments, and the resident's seizure medication was scheduled on incorrect days, not aligning with the updated dialysis schedule. The Assistant Director of Nursing (ADON) confirmed that the dialysis days had changed, but the medication order was not updated accordingly, and the required assessments could not be located in the resident's records. Another resident, also dependent on dialysis, did not have her dialysis binder sent to the dialysis center on two occasions, and her prescribed medications were not sent with her as ordered. The resident reported that staff failed to send both her binder and medications, and the ADON confirmed that the prepackaged medications were found in the medication cart rather than being sent with the resident. The facility's own dialysis protocol required that medications to be administered during or after dialysis be labeled and sent with the resident, which was not followed in these instances.