Failure to Maintain Required Dialysis Communication Documentation
Penalty
Summary
Facility staff failed to maintain ongoing communication with an outpatient dialysis center for a resident who was dependent on renal dialysis. The resident was admitted with diagnoses including sepsis, dependence on renal dialysis, and diabetes, and had a physician’s order to receive hemodialysis three days per week. The facility’s dialysis care plan included interventions to monitor pre- and post-dialysis weights, encourage attendance at scheduled dialysis appointments, and monitor vital signs with physician notification of significant abnormalities. The facility had a “Dialysis Management” policy stating it had designed and implemented processes to ensure the comfort, safety, and appropriate management of hemodialysis residents. Review of dialysis communication forms from January through April showed that 12 of 16 pre-dialysis communication forms were not completed by facility nursing staff on specified dialysis dates, and 16 additional dialysis communication sheets for other dialysis days were possibly missing and not available at the facility. The RN Assessment Coordinator confirmed that the facility failed to ensure the dialysis communication forms were completed pre- and post-treatment between the facility and the dialysis center and confirmed the missing sheets were not available. The Nursing Home Administrator also confirmed that the facility failed to ensure dialysis communication sheets were completed prior to dialysis treatment.
Plan Of Correction
Resident R1 receiving Dialysis will be reviewed with the Dialysis Nurse to ensure complete communication has occurred to provide for accurate Plan of Care for the residents. Resident receiving Dialysis will be reviewed with the Dialysis Nurse to determine that complete communication has occurred and that the accurate Plan of Care is in place for the resident. The Medical records staff will be educated to not upload any Dialysis communication that is not complete. Medical Records staff will communicate with the DON/Designee if this occurs. Nursing Staff will be educated on the need for accurate completion of the Dialysis Communication Form by the DON /Designee Audit of 10% of residents receiving Dialysis will have the Dialysis Communication form audited for completion and placement in the Resident Medical Record by the DON/Designee. These will be completed weekly times four and monthly times three. Results on these audits will be submitted to the QAPI committee for review and further recommendations.
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