HospitalInspections.org

Based on documentation review and staff interview the facility failed to ensure nursing staff took appropriate action to ensure that a patient identified as needing dialysis treatment on admission received dialysis treatment timely during the hospital stay. This affected one (Pt #1) of 10 sampled patients. The facility census was 59.

Findings include

Review of Pt #1's medical record revealed an admission date of 11/06/19 and a transfer date of 12/10/19 with diagnosis of congestive heart failure. The history and physical identified Pt #1 as having dialysis on 11/06/19 before admission and the patient informed the physician that he/she was due for another dialysis treatment on 11/08/19.

Review of the physician's order revealed a nephrology consult was not ordered until 11/08/19 at 4:22 PM. the same day the Pt #1 stated his/her next dialysis treatment was due. The consultation for nephrology was completed on 11/11/19 and hemo dialysis was completed on same day; three days past when the dialysis treatment was supposed have been given according to Pt #1.

Interview with Staff B completed on 11/14/20 at 9:45 AM revealed that he/she had no answer to why the nephrology consult was not ordered on admission.