Failure to Ensure Proper Dialysis Communication and Documentation
Penalty
Summary
The facility failed to ensure that a resident requiring dialysis received care and services consistent with professional standards of practice, specifically regarding communication and collaboration with the dialysis center. The resident had multiple complex medical conditions, including end-stage renal disease, acute osteomyelitis, sepsis, chronic ulcers, diabetes mellitus, anemia, peripheral vascular disease, muscle weakness, and fatigue. The resident was highly dependent on staff for activities of daily living and had ongoing pain, unhealed pressure ulcers, and a surgical wound. The care plan and physician orders required staff to complete and send a dialysis communication sheet with the resident to the dialysis center and ensure it was returned and completed for each visit. Despite these directives, the facility failed to provide the required information on the resident's condition on the dialysis communication form for multiple documented dates. Staff confirmed that they did not complete the necessary sections of the form as required by facility policy and physician orders. The facility's policy specified that the nurse in charge was responsible for initiating and sending the communication form with the resident on dialysis days, but this process was not consistently followed, resulting in incomplete communication between the facility and the dialysis center.