Failure to Maintain Dialysis Communication Documentation in Medical Record
Penalty
Summary
The deficiency involves the facility’s failure to maintain evidence of ongoing communication with a dialysis treatment center in the medical record for a resident with end stage renal disease (ESRD) who was dependent on hemodialysis three times per week. The resident’s significant change MDS assessment showed the resident was cognitively intact, but dialysis was not coded on the assessment in error. Review of the electronic medical record revealed no completed dialysis communication forms, and the facility was unable to locate any such forms for this resident. Progress notes contained no documentation of communication between facility staff and the dialysis center, and there was no documentation that pre-dialysis or post-dialysis assessments were completed and communicated. Nursing staff interviews confirmed that a dialysis communication form and notebook system was in place, with nurses completing pre-dialysis information such as vital signs, weight, access site condition, and changes in condition, and dialysis nurses documenting post-dialysis assessments. However, the Medical Records Manager reported there was no scheduled timeframe for removing completed forms from the notebook and uploading them into the electronic medical record, and she was unable to locate any forms for this resident, suggesting they may have remained in the notebook and possibly left with the family at discharge. The DON stated the facility was responsible for ensuring completion of the forms and placement in the medical record after review, but could not explain why the forms were not present for this resident.
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