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|WADLEY REGIONAL MEDICAL CENTER||1000 PINE STREET TEXARKANA, TX 75501||Jan. 17, 2012|
|VIOLATION: MEDICAL RECORD SERVICES||Tag No: A0450|
|Based on record review and interview, the facility failed to assure hemodialysis orders contained all necessary components. 7 of 16 hemodialysis orders lacked an order for blood flow rate and dialysate flow rate. There was also no target weight (or dry weight) ordered/documented for 1 of 1 patient.
Further review of patient #1 ' s chart revealed no order for blood flow rate or dialysate flow rate for 7 of 16 hemodialysis treatments on the following dates: 9/14/11, 9/16/11, 9/18/11, 9/20/11, 10/03/11, 10/10/11, and 10/12/11.
Review of patient #1 ' s medical record revealed no documented target weight (or dry weight).
During an interview on 1/18/12 at 1:25pm in the administrative offices, staff #2 reported the following:
-The patient ' s weight gain since the last dialysis treatment (interval weight gain) is the amount of weight that should be removed during the dialysis treatment
-If the interval weight gain is not the target, the physician should write an order for the target weight
-Staff #2 was not aware of a policy or standing order that specified the amount of weight that should be removed during a dialysis treatment
Review of the hemodialysis policy and procedures revealed no policy guidance for weight to be removed during a dialysis treatment.