Failure to Ensure Ongoing Assessment and Communication for Dialysis Care
Penalty
Summary
The facility failed to ensure ongoing assessment and monitoring for complications before and after dialysis treatments for a resident with end stage renal disease who was dependent on hemodialysis. The resident's care plan required monitoring and documentation of signs and symptoms related to renal insufficiency and dialysis complications, as well as communication with the dialysis facility using a designated Dialysis Communication Form. However, review of the electronic medical record and interviews revealed that these forms were either missing or incompletely filled out for multiple dialysis sessions. Specifically, only one form was found in the facility records, and it was largely incomplete, missing documentation on vital signs, code status, blood glucose, food intake, cognitive orientation, pain, and changes in condition. Another form located by dialysis staff was also incomplete, lacking the pre-dialysis weight. The dialysis registered nurse confirmed that the facility staff were responsible for completing the pre-dialysis section but did not always do so, and the forms were not consistently uploaded into the system as required. Additionally, an LPN reported that due to high unit traffic and frequent admissions or discharges, she was not always able to complete the dialysis communication report or monitor the resident's vital signs as required. Facility policy mandated thorough communication with the dialysis facility, including timely medication administration, vital signs, code status, nutrition/fluid management, and documentation of dialysis treatment and resident response. The lack of consistent and complete documentation and communication between the facility and the dialysis provider constituted a failure to follow policy and ensure safe, appropriate dialysis care for the resident.