Failure in Medication Management, Documentation, and Adherence to Physician Orders for Dialysis Residents
Penalty
Summary
The facility failed to ensure proper medication management, accurate documentation, recognition of changes in condition, and adherence to physician orders for two residents with end-stage renal disease dependent on dialysis. For one resident, there was an active physician order for transport to dialysis on specific days and notification of the physician for missed appointments, as well as weight monitoring. The resident's dialysis schedule was altered without justification or documentation, and there was no evidence of physician notification or weight documentation for missed or changed dialysis sessions. Additionally, the resident did not receive the prescribed Sevelamer HCl for chronic kidney disease, with multiple doses marked as administered on the MAR despite the medication not being available in-house. Nurses' notes indicated the medication was not available, and the DON confirmed the MAR entries were inaccurate and that the medication was never present during the resident's admission. The same resident experienced poor oral intake, with documentation showing less than 75% meal consumption at every meal and no evidence that snacks or alternatives were offered. There was only one recorded weight during the admission, reflecting a significant weight loss, with no documentation addressing the cause or interventions. The resident did not receive a Registered Dietician consultation or progress notes, and required social services assessments were not completed until after discharge. The social worker reported being unable to complete assessments due to the resident's lethargy but did not notify nursing staff, and there was no documentation of assessment attempts. Family members reported concerns about the resident's eating difficulties and mood changes, which were not addressed by the facility. For the second resident, there was also a failure to adhere to the prescribed dialysis schedule and to notify the physician or document weights when dialysis was missed or altered. The resident missed a dialysis session due to the facility not sending the required Hoyer sling, and there was no documentation of physician notification or weight monitoring. Dialysis communication forms were missing from the medical record, and staff could not explain the changes to the dialysis schedule. These deficiencies demonstrate a lack of compliance with physician orders, medication management, documentation, and recognition of changes in condition for residents requiring complex care.