Incomplete Dialysis Documentation and Assessment
Penalty
Summary
The facility failed to provide dialysis care and services consistent with professional standards of practice for a resident requiring hemodialysis. According to facility policy, staff are required to conduct ongoing assessments of the resident's condition and monitor for complications before and after dialysis treatments, as well as maintain ongoing communication and documentation with the dialysis center. Review of the medical record for a resident with end stage renal disease and multiple comorbidities revealed that the Hemodialysis Communication Record was not consistently or completely filled out by either facility staff or the dialysis center on 23 occasions since a specified date. Additionally, on at least one occasion, the required pre- and post-dialysis assessments, including checks for bruit, thrill, vital signs, last meal, diet, and general condition, were not completed by facility staff. Interviews with nursing staff and the DON confirmed that the Hemodialysis Communication Record was not being fully completed as required, and that both facility and dialysis center staff were responsible for documenting their respective portions. The DON also confirmed that nursing staff were not consistently assessing the resident's condition before departure to dialysis and upon return, nor ensuring that the dialysis center completed its documentation. The Unit Manager was identified as responsible for ensuring the records were complete and for contacting the dialysis center when documentation was missing.