Failure to Maintain Consistent Dialysis Communication and Documentation
Penalty
Summary
The facility failed to maintain consistent and complete communication regarding dialysis care for two residents who required regular hemodialysis treatments. According to facility policy, ongoing communication and collaboration with the dialysis provider is required, including the use of telephone or written communication such as dialysis communication forms. For both residents, who had diagnoses including end stage renal disease, diabetes, seizures, high blood pressure, and anemia, physician orders and care plans specified dialysis three times weekly. However, a review of dialysis record of visit forms over a specified period revealed that all forms for both residents were incomplete. Interviews with the Director of Nursing confirmed that the required documentation was not fully completed for these residents, resulting in a lack of consistent communication with the dialysis facility. This deficiency was identified through review of clinical records, facility policy, and staff interviews, and was cited under relevant state codes for clinical records and nursing services.