Failure to Reinstate Dialysis Order After Resident Readmission
Penalty
Summary
The facility failed to ensure a resident receiving hemodialysis had an active physician’s order for dialysis following readmission from the hospital. The resident, who had end-stage renal disease and chronic renal failure requiring dialysis, was admitted with a care plan that identified the need for hemodialysis and included interventions such as coordinating care with the dialysis center, communicating about medications, diet, and labs, and monitoring the shunt site for infection, pain, bleeding, and absence of thrill or bruit. After the resident was hospitalized for a critical procedure related to long-term dialysis access and then returned to the facility, the physician’s orders on readmission did not include dialysis services, despite the resident’s MDS coding indicating end-stage renal disease and ongoing dialysis. The Annex Unit Manager confirmed there was no dialysis order in the chart after the resident’s return and stated the order was not reinstated, and the DON acknowledged she was unaware the dialysis order was missing and that staff likely failed to re-enter it, while the Administrator stated the dialysis order should have been immediately reinstated after the resident’s return. These findings show that although the resident’s condition and need for dialysis were documented in the care plan and MDS, the facility did not obtain or re-enter a physician’s order for dialysis services upon readmission from the hospital, resulting in the resident receiving dialysis without a corresponding physician’s order in the medical record.
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