Failure to Coordinate and Document Dialysis-Related Communication and Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure effective, documented communication and coordination with an outpatient dialysis center for a resident receiving hemodialysis, resulting in missed communication needed for continuity of care. The resident, who had end stage renal disease, dysphagia, dementia, psychotic disturbance, mood disturbance, anxiety, and schizophrenia, was observed on multiple occasions to be anxious, restless, angry, and agitated, including when preparing to leave for dialysis. The resident required assistance with most daily activities and had severe cognitive impairment and unclear speech. The dialysis care plan dated 6/9/24 did not include person-centered goals or interventions that adequately addressed the resident’s dialysis-related needs, including behavioral issues associated with dialysis treatments. Dialysis communication forms from the dialysis center documented agitation during treatments on specific dates, and the dialysis center reported that the resident frequently arrived very angry and anxious, requiring up to 40 minutes to calm before treatment. Dialysis staff stated they had repeatedly notified the facility, both by phone and in writing, about the resident’s behaviors and the need for medications to be administered prior to dialysis. On one date, an RN reported that an ordered antianxiety medication was not available at the facility before the resident left for dialysis and that a prescription was needed to obtain it, but the RN did not document the telephone communication with the dialysis center. Requested dialysis communication forms for several treatment dates were not present in the electronic medical record and could not be produced when requested by the DON, who acknowledged documentation was an area needing improvement. The facility’s own dialysis guideline required written communication and review of pertinent information between the dialysis provider and the facility, which was not consistently implemented for this resident.
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