Failure to Maintain Complete Dialysis Assessments and Communication Records
Penalty
Summary
The facility failed to maintain complete and accurate records and communication related to dialysis care for a resident receiving hemodialysis. Facility policy on dialysis care required communication with the dialysis center, completion of pre-dialysis observations to be sent or faxed to the dialysis center, and completion of post-dialysis observations with notification of the physician and dialysis center as needed. The resident’s clinical record showed diagnoses of end stage renal disease and dependence on renal dialysis, with physician orders for pre- and post-dialysis observations on specified days and times. The care plan documented that the resident had hemodialysis due to renal failure, with interventions including dialysis treatments on specific days, monitoring and documenting vital signs and weight, and dialysis treatments per physician order. However, there were no documented physician orders for dialysis itself. Review of the electronic medical record revealed that complete pre- and post-dialysis assessments were not documented on multiple specified dates, and the assessments that were completed did not include weight monitoring as required by the care plan. An LPN stated that the facility did not maintain documentation of communication with the dialysis center and that pre- and post-dialysis assessments were limited to monitoring blood pressure, not weight. The DON stated that pre- and post-dialysis assessments should be completed and that communication between the dialysis center and the facility should be available. These findings showed noncompliance with facility policy and state regulations regarding clinical records and nursing services for dialysis care.
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