Failure to Ensure Safe and Coordinated Dialysis Care
Penalty
Summary
The facility failed to ensure that a resident requiring dialysis received care and services consistent with professional standards of practice, specifically regarding communication and monitoring before and after dialysis treatments. The facility's policy required staff to communicate with the dialysis center before and after each treatment using a designated communication form and to coordinate care plans, including any special considerations and emergency contacts. However, for one resident with a complex medical history—including end stage renal disease on hemodialysis, congestive heart failure, COPD, diabetes with complications, and a history of unresponsive episodes primarily after dialysis—these procedures were not followed. The resident had recently been hospitalized for chest pain and shortness of breath, during which multiple unresponsive episodes occurred, mostly during hemodialysis. Hospital records indicated that these episodes were likely functional neurologic syndrome and recommended close monitoring, with instructions not to send the resident to the hospital unless new symptoms arose. Despite this, the facility did not document the resident's history of unresponsive episodes or the need for additional monitoring after dialysis. On one occasion, after returning from dialysis, the resident complained of a headache, had difficulty speaking, and exhibited abnormal vital signs, but there was no documentation of a post-dialysis assessment or evidence that staff were aware of the resident's specific risks. Review of facility records showed that the dialysis communication form for the relevant date was not completed upon the resident's return, and there was no evidence that staff contacted the dialysis center to obtain a report as required by policy. Nursing staff interviewed were not aware of any special monitoring needs for the resident, and documentation of vital signs lacked time stamps. The lack of communication and failure to follow established procedures resulted in the resident not receiving dialysis care and monitoring consistent with professional standards.