Failure to Communicate and Implement Fluid Restriction for Dialysis Resident
Penalty
Summary
The facility failed to ensure consistent communication with the dialysis center regarding fluid restrictions for a resident with end-stage renal disease (ESRD) who was dependent on dialysis. The facility's hemodialysis policy required coordination and collaboration with the dialysis center to implement the dialysis care plan, but this was not followed. The resident, who was cognitively intact and independent in most activities of daily living, was observed with multiple fluid items in their room and expressed uncertainty about their fluid restriction and who was responsible for monitoring it. Review of the resident's care plan and provider orders revealed no mention of oral fluid restrictions or interventions to monitor fluid intake, despite the dialysis center's Registered Dietician stating the resident was supposed to be on a 1200 ml daily fluid restriction. Documentation of fluid intake was inconsistent, with many omissions and no data recorded for fluids given as needed. The facility's Registered Dietician was unaware of the fluid restriction recommendation and had not communicated with the dialysis center, while nursing staff were unclear about who determined and monitored fluid restrictions for dialysis residents. Interviews with facility staff indicated a lack of clear processes for communicating dietary or fluid needs between the facility and the dialysis center. The communication sheet sent with the resident to dialysis was used for general updates, but there was no evidence of direct communication regarding the resident's fluid restriction. As a result, the resident's fluid intake was not adequately monitored or restricted according to the dialysis center's recommendations.