Failure to Document and Coordinate Dialysis Care
Penalty
Summary
The facility failed to ensure that residents requiring dialysis received services consistent with professional standards, their care plans, and their individual goals and preferences. Specifically, for three residents reviewed, there was inadequate documentation regarding offsite hemodialysis treatments at an ESRD unit. Record reviews revealed that care plans identified the need for regular dialysis and associated interventions, such as monitoring access sites and documenting post-dialysis weights and communication from the dialysis center. However, there were no active orders for dialysis treatment or care of dialysis access sites in the residents' records, and required documentation such as post-dialysis weights and communication forms from the dialysis center were missing for extended periods. Interviews with staff, including LVNs and the DON, confirmed that there was no consistent process for collecting and maintaining dialysis communication forms from the dialysis center. Staff reported that forms were sometimes lost or not returned, and there was no centralized system for tracking these documents. Additionally, the DON acknowledged that orders were not always reactivated when residents returned from the hospital, and the admitting nurse was responsible for ensuring orders were in place. The CNA responsible for pre- and post-dialysis weights indicated that her schedule did not always align with residents' return from dialysis, leading to missed documentation. Despite residents reporting that they attended all scheduled dialysis appointments and had no concerns about their care, the facility's records did not reflect adequate documentation of dialysis treatments, post-dialysis monitoring, or communication with the dialysis center. The lack of active orders and missing documentation could result in incomplete monitoring and care for residents receiving dialysis, as evidenced by the findings during the survey.