Failure to Maintain Dialysis Coordination and Documentation
Penalty
Summary
The facility failed to maintain required dialysis coordination and communication documentation for two residents who required dialysis services. Both residents had physician orders specifying dialysis schedules and instructions to notify the physician of missed appointments and to obtain weights. However, the medical records for both residents lacked dialysis communication forms, documentation of physician notification, and records of weights when dialysis appointments were missed or altered. Staff were unable to explain or justify changes to the dialysis schedules, and there was no documentation to support why the residents' dialysis days were changed from the ordered schedule, despite the dialysis center being open on the originally scheduled days. One resident was not sent with the necessary Hoyer sling for transfer at the dialysis center, resulting in an incomplete dialysis session, and there was no documentation that the physician was notified or that a weight was obtained. The other resident's dialysis days were altered without explanation or documentation, and again, there was no evidence of physician notification or weight documentation. The Director of Nursing acknowledged that dialysis communication forms could not be located and that the facility was working to improve the process.