Failure to Complete Required Dialysis Communication Documentation
Penalty
Summary
Facility staff failed to provide complete dialysis communication for a resident with end stage renal disease (ESRD) who required hemodialysis and had a left arm AV fistula. According to the clinical record and physician orders, staff were required to complete a dialysis communication form and record vital signs prior to transporting the resident to dialysis on each treatment day. However, review of the Hemodialysis Communication Records revealed multiple instances across November, December, and January where pre-dialysis or dialysis communication forms were not completed as required. The resident's care plan documented the ongoing need for hemodialysis, and staff interviews confirmed the process for completing and transmitting dialysis communication forms. Despite this, there were several dates where no documentation was present, indicating a failure to follow established protocols and facility policy, which required routine communication of relevant information to the dialysis center on treatment days.