Incomplete Post-Dialysis Evaluation Documentation for Hemodialysis Resident
Penalty
Summary
The deficiency involves the facility’s failure to complete required post-dialysis evaluation documentation for a resident who received hemodialysis. The resident was admitted with multiple diagnoses, including DM type 2, muscle weakness, COPD, heart failure, HTN, ESRD, and dependence on renal dialysis. An MDS assessment indicated the resident had intact cognition and required varying levels of assistance with ADLs, and that the resident received hemodialysis treatments. During a concurrent interview and record review with an LVN, the surveyor reviewed the resident’s pre- and post-dialysis evaluation records for March and found that the post-dialysis evaluation for a specific treatment date was missing from the medical record. The LVN confirmed that the post-dialysis evaluation for that date was not present in the record and acknowledged that this omission could result in missing changes of condition or medications given during the treatment. Review of the facility’s “Dialysis Management” policy, last reviewed on 6/20/25, showed that a pre- and post-dialysis evaluation was required to be completed by a licensed nurse and that all documentation concerning dialysis services and care of dialysis residents must be maintained in the resident’s medical record. The missing post-dialysis evaluation demonstrated that the facility did not follow its own policy and procedures for dialysis management and did not maintain a complete medical record for this resident.
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