Incomplete and Missing Dialysis Communication Forms for a Dialysis-Dependent Resident
Penalty
Summary
The facility failed to provide complete dialysis-related care and services for a resident with end-stage renal disease who was admitted with a physician’s order to receive dialysis three times a week. Review of the resident’s clinical record and dialysis communication forms for September showed that required pre-dialysis information was frequently incomplete or missing. On multiple dates, the pre-dialysis communication forms lacked documentation of meals, medications, changes in condition, and the signature of the person completing the form. For example, on one date only blood pressure and pulse were documented, and on another date only blood pressure, pulse, and a staff signature were recorded. On two additional dates, the pre-dialysis communication forms were completely blank. Further record review revealed that dialysis communication forms for several scheduled dialysis visits were absent from the medical record. Specifically, there was no evidence of completed forms for three dialysis dates early in the month. During interviews, the medical records staff member confirmed that the forms for those dates could not be located. An LPN stated that assigned nurses are responsible for completing the dialysis communication form and described that they ensure the resident has medications, obtain vital signs, and get food from the kitchen before sending the resident to dialysis with a yellow folder given to transportation. The RN unit manager on the resident’s unit confirmed the findings, and the deficiency was later reviewed with the NHA, DON, and corporate nurse during the exit conference.
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