Incomplete Dialysis Communication Documentation for Resident Requiring Hemodialysis
Penalty
Summary
The facility failed to ensure that a resident requiring hemodialysis received services consistent with professional standards and its own dialysis communication policy. The facility’s Dialysis Guidelines policy required shared communication between the center and the dialysis facility using a Hemodialysis Communication Form, including timely documentation of medications, physician/treatment orders, laboratory values, vital signs, and weights. The clinical record for Resident 45, who had hypertension and end-stage renal disease and required renal dialysis on Monday, Wednesday, and as needed, showed incomplete Hemodialysis Communication Record Forms. On one date, the dialysis center did not document the resident’s post-dialysis weight, and on another date, the dialysis center did not document blood pressure, pre-dialysis weight, post-dialysis weight, medications given during hemodialysis, or pulse. In an interview, the Director of Nursing confirmed that the missing documentation on the communication forms should have been completed. These findings were cited under 28 Pa. Code 211.12 (d) (1) (2) (5) related to nursing services.
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