Failure to Document and Communicate Dialysis Care for Residents
Penalty
Summary
The facility failed to ensure that residents requiring dialysis received care and services consistent with professional standards, the comprehensive person-centered care plan, and the residents' goals and preferences. For two residents with diagnoses including end stage renal disease and chronic kidney disease, physician orders and care plans specified scheduled dialysis treatments. However, documentation of communication between the facility and the dialysis provider was either missing or incomplete. Specifically, for one resident, there were no dialysis communication sheets available for review, and for the other, there was a lack of documented communication for a period during which the resident attended multiple dialysis sessions. Interviews with the Nursing Home Administrator confirmed that dialysis communication sheets were not consistently completed or available for review, and that these records were not uploaded to the electronic health record. The facility's own policy required immediate communication with the attending physician, resident or representative, and dialysis staff regarding significant changes in the resident's status, but there was no evidence that this communication occurred or was documented as required.