Failure to Monitor and Intervene After Multiple Missed Dialysis Treatments
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices. Specifically, the resident, who had multiple diagnoses including chronic kidney disease and was dependent on dialysis, refused three consecutive dialysis treatments. Despite this, there was no documentation of the missed treatments for two of the dates, nor were there documented attempts to send the resident to the hospital for evaluation after missing three treatments. The care plan was only updated to address dialysis non-compliance after the surveyor entered the facility. The resident's medical records indicated significant health concerns, including metabolic encephalopathy, heart failure, diabetes, morbid obesity, COPD, and major depressive disorder. The resident required extensive assistance with most activities of daily living and had moderate cognitive impairment. Laboratory results showed several abnormal values, including elevated glucose, BUN, and creatinine, as well as low albumin and total protein, which were not promptly reviewed or acted upon by the clinical team. The resident reported feeling slightly bloated but otherwise fine, and interviews revealed that the facility staff, including the PA and MD, were aware of the refusals but did not follow established protocols for monitoring or escalation. Interviews with facility staff and the dialysis center social worker highlighted a lack of communication and follow-up after the resident missed multiple dialysis sessions. The facility's policy required documentation and notification when a resident refused dialysis but did not specify follow-up procedures for care after refusal. The PA admitted to not reviewing critical lab results in a timely manner, and the facility did not ensure appropriate monitoring or intervention after repeated missed treatments, placing the resident at risk for delayed medical evaluation and treatment.