Failure to Coordinate Dialysis Medication Management and Communication
Penalty
Summary
The facility failed to ensure ongoing communication and collaboration with an outside dialysis center regarding the dialysis care and services for a resident with end stage renal disease, diabetes, and a left leg below the knee amputation. The resident, who was cognitively intact, attended hemodialysis three times weekly at an external facility. A critically low hemoglobin level was identified, and orders were given for increased iron supplementation and weekly Epoetin alfa injections. However, the Epoetin alfa was not administered as scheduled on multiple occasions due to unavailability from the pharmacy, and there was no evidence that the physician was notified of these missed doses. Simultaneously, the dialysis center administered Mircera, a medication from the same drug class as Epoetin alfa, every two weeks, but was unaware of the facility's order for Epoetin alfa. Communication reports between the facility and the dialysis center were incomplete or delayed, and did not consistently document medications administered at the dialysis center. Interviews with staff and review of the contract confirmed that there was a lack of required collaboration and information exchange regarding the resident's dialysis-related medications and care.