Failure to Ensure Timely Dialysis for Resident After Readmission
Penalty
Summary
A resident with end stage renal disease, dependent on renal dialysis, was admitted to the facility with orders for hemodialysis on specific days. The resident missed two scheduled dialysis treatments due to a failure in obtaining the necessary consent and completing required paperwork for dialysis services following a readmission from an acute hospital stay. The resident was not able to make their own decisions, and consent from the family was required but not obtained in time. As a result, the resident did not receive dialysis as ordered by the physician and was subsequently sent to an acute hospital for treatment. Interviews with facility staff revealed confusion and lack of clarity regarding the process for re-establishing dialysis services after a resident's discharge and readmission. The Admission Coordinator acknowledged not being aware that the resident needed to be treated as a new admission for dialysis purposes and did not complete the necessary paperwork or obtain consent in a timely manner. The DON confirmed that the responsibility for ensuring dialysis authorization and documentation rested with the facility, and the delay in obtaining consent led to the missed treatments.