Failure to Document and Communicate Resident Status Before and After Dialysis
Penalty
Summary
The facility failed to ensure proper communication regarding a resident's health status or changes in condition before and after dialysis treatments. According to facility policy, residents receiving dialysis are to be monitored, and relevant medical information from the dialysis provider must be maintained in the resident's medical record. If such information is not received upon the resident's return, the facility is required to contact the dialysis provider to obtain it. For one resident with end-stage renal disease who was cognitively intact and dependent on hemodialysis, physician orders and the care plan specified that vital signs and weight were to be recorded before dialysis and that open communication with the dialysis center was necessary. However, review of the resident's clinical record and dialysis binder revealed no documented evidence of communication between the facility and the dialysis center regarding the resident's health status before and after dialysis on multiple occasions. Nursing notes and the medication administration record confirmed that the resident attended dialysis on several dates, but there was no documentation of the required communication. The Director of Nursing confirmed that such documentation was missing and acknowledged that it should have been present.