Failure to Obtain Physician Orders for Dialysis Care
Penalty
Summary
The facility failed to ensure that two residents requiring dialysis had appropriate physician orders for their dialysis treatments. Both residents had documented diagnoses of end-stage renal disease and were receiving dialysis, as reflected in their care plans and through staff interviews. However, a review of their electronic health records and physician orders for multiple months revealed that there were no orders for completing dialysis or for obtaining and documenting vital signs before and after dialysis sessions. Despite the care plans outlining specific interventions related to dialysis care, such as monitoring for complications, checking the access site, and encouraging attendance at scheduled dialysis appointments, these interventions were not supported by corresponding physician orders. Nursing staff and management interviews confirmed that the admitting nurse was responsible for entering these orders, but the orders were not present in the system. Staff were unaware of the missing orders until an audit was conducted, and both the unit manager and DON acknowledged the oversight. The facility's own hemodialysis policy required detailed physician orders for dialysis, including the type and location of access, dialysis schedule, nephrologist and facility contact information, transportation arrangements, and medication or fluid restrictions. The absence of these orders meant that staff relied on care plans and communication forms but lacked the formal physician directives necessary for consistent and safe dialysis care.