Failure to Obtain Physician Order for Hemodialysis
Penalty
Summary
The facility failed to ensure that a resident requiring hemodialysis had a physician's order for the treatment, despite the resident attending dialysis three times a week. Documentation reviewed included the resident's face sheet, baseline care plan, hospital records, admission assessment, and dialysis communication forms, all of which confirmed the resident's dependence on and receipt of dialysis. However, there was no physician's order for hemodialysis in the resident's chart as of the date reviewed. Interviews with nursing staff and the DON confirmed that the absence of such an order could result in staff being unaware of the resident's dialysis needs, especially if they were unfamiliar with the resident. The resident's baseline care plan noted dependence on renal dialysis but did not specify that dialysis was being received. The facility's policies require that orders for dialysis and related care be obtained and followed upon admission, including shunt care and monitoring. Despite these requirements, the necessary physician's order for dialysis was missing, and staff relied on verbal reports or the resident's own disclosure to know about the dialysis schedule. This lack of formal documentation and orders was directly observed and acknowledged by staff during interviews.