SPARKS, NV - Federal inspectors found significant lapses in medical record keeping and dialysis patient monitoring at Hearthstone of Northern Nevada during a March 2025 inspection, with violations affecting the care of six residents requiring life-sustaining dialysis treatments.
Critical Gaps in Dialysis Patient Monitoring
The most serious violations centered on incomplete documentation for residents receiving hemodialysis, a critical medical procedure that filters waste and excess fluid from the blood when kidneys fail. Inspectors found that six dialysis patients had incomplete or missing hemodialysis communication forms, which serve as the primary tool for coordinating care between the nursing facility and external dialysis centers.
These communication forms are designed to track vital patient information before, during, and after each dialysis session. According to physician orders reviewed by inspectors, nursing staff were required to document vital signs, assess dialysis access sites for complications, record medications given or withheld, and note any changes in patient condition. The dialysis center was responsible for completing the middle section with treatment details, while facility nurses completed post-dialysis assessments upon the resident's return.
However, inspectors documented numerous instances where critical information was missing. For one resident, forms lacked access site assessments, vital signs, pain evaluations, and medication documentation across multiple dialysis visits spanning several months. Another resident's records showed missing dialysis center information including treatment start and end times, weight measurements, and access site evaluations.
One Licensed Practical Nurse explained to inspectors that an incomplete or missing hemodialysis communication form meant "the resident could be in trouble metabolically and the form was one way to track what was happening at the time and informing the nurse of what occurred during dialysis."
Medical Significance of Dialysis Documentation
Complete dialysis documentation is crucial because patients with end-stage renal disease face extremely high mortality rates, with sudden cardiac death being the most common cause. Dialysis treatments cause significant shifts in electrolytes and fluid volume that can trigger life-threatening heart rhythm abnormalities. These rapid changes in blood chemistry require careful monitoring to identify early warning signs of complications.
Access site monitoring is equally critical, as the arteriovenous fistula or graft used for dialysis access can develop infections, blood clots, or structural problems that threaten both the access and the patient's life. Proper assessment includes checking for adequate blood flow through the access site and identifying signs of infection or dysfunction that require immediate medical attention.
Medication management around dialysis is also complex, as certain medications may need to be held before treatment to prevent dangerous interactions with the dialysis process. Some medications are removed during dialysis and may need to be replaced afterward. Without proper documentation of which medications were given or withheld, subsequent caregivers cannot make informed decisions about continuing or adjusting treatments.
Weight Loss Monitoring Failures
Inspectors also identified concerning gaps in monitoring a resident experiencing significant weight loss while taking Ozempic, a diabetes medication known to cause appetite suppression and weight reduction. The resident lost 24.7 pounds over approximately seven weeks, representing a 10.12% weight loss in the first month alone, followed by an additional 5.05% loss in the following 20 days.
Despite this dramatic weight loss, meal consumption documentation was incomplete across multiple days and meals. The facility's meal consumption logs showed numerous entries marked as "no documentation found" for breakfast, lunch, or dinner on various dates. When documentation was present, it often showed the resident consuming only 0-25% or 26-50% of meals, with some complete meal refusals.
The facility's Registered Dietitian told inspectors that "the documentation was important so the Registered Dietitian could figure out what the reasoning was for the weight loss and address the concern so the resident would not experience any health problems related to the weight loss." The Director of Nursing Services confirmed that complete meal consumption logs were necessary "to be able to determine what issues the resident could be experiencing with the resident's health."
Industry Standards for Medical Record Keeping
Federal regulations require nursing homes to maintain complete and accurate medical records that follow accepted professional standards. For dialysis patients, this includes comprehensive documentation of all aspects of care coordination with external treatment facilities. The American Association of Kidney Patients emphasizes that communication between dialysis centers and nursing facilities is essential for patient safety and optimal outcomes.
Proper weight monitoring protocols require daily documentation of food intake percentages when residents experience significant weight loss. This allows healthcare providers to identify patterns, assess nutritional status, and implement interventions before malnutrition or other complications develop. Weight loss exceeding 5% in one month or 10% in six months is considered clinically significant and requires immediate evaluation and intervention.
Quality Assurance Program Deficiencies
Beyond the direct care issues, inspectors found that the facility's Quality Assurance and Performance Improvement (QAPI) committee had failed to identify these systematic problems with dialysis documentation and medical record keeping. The Executive Director acknowledged that the QAPI committee had not identified the lack of a process to ensure pre and post dialysis assessments, documentation of the assessments, and communication with the dialysis center was completed and correctly documented.
This represents a failure at the administrative level to maintain oversight systems that could have prevented these documentation gaps from continuing unchecked. Effective QAPI programs are designed to proactively identify risks and implement corrective measures before patient safety is compromised.
Additional Issues Identified
Inspectors documented several other violations during the inspection. Multiple residents had incomplete dialysis communication forms missing essential clinical information such as vital signs, medication administration records, access site assessments, and treatment timing documentation. The facility's transportation logs confirmed dialysis appointments occurred, but corresponding medical documentation was either incomplete or entirely absent.
Staff interviews revealed that while nurses understood the importance of complete dialysis documentation, the facility lacked effective systems to ensure forms were properly completed and verified before and after each treatment. The Director of Nursing Services confirmed responsibility for coordinating dialysis care but acknowledged that critical documentation requirements were not being consistently met.
The inspection findings highlight systemic issues with medical record management that extend beyond individual documentation errors to fundamental gaps in quality oversight and staff accountability for maintaining complete patient records.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Hearthstone of Northern Nevada from 2025-03-03 including all violations, facility responses, and corrective action plans.
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