Failure to Implement Dialysis Communication and Updated Antihypertensive Orders
Penalty
Summary
The deficiency involves the facility’s failure to provide dialysis-related care and medication management according to professional standards for a resident with end stage renal disease and diabetes who required hemodialysis three times weekly. The resident’s care plan noted the need for hemodialysis and listed interventions such as administering medications as ordered and encouraging attendance at scheduled dialysis sessions. However, review of the medical record showed that dialysis communication forms were missing for two dialysis dates, and the existing dialysis communication form documented a change in the resident’s Amlodipine dosage from 10 mg to 5 mg daily that was not implemented in the medical record. The physician’s order in the chart continued to show Amlodipine 10 mg by mouth on specific days with hold parameters, and there was no documentation of the decreased 5 mg daily dose as communicated by dialysis. The DON and Regional Nurse Consultant acknowledged that the Amlodipine dose in the record was incorrect, that the dose should have been 5 mg every day, and that dialysis communication sheets for two dates were missing.
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