SPARKS, NV - Federal inspectors found systemic failures in dialysis patient care protocols at Hearthstone of Northern Nevada, citing the facility for inadequate administration that compromised the quality of care for kidney patients requiring life-sustaining treatment.
Critical Gaps in Dialysis Care Coordination
The March 3, 2025 inspection revealed that Hearthstone failed to establish proper processes for conducting pre and post-dialysis assessments, documenting these critical evaluations, and maintaining communication with dialysis centers. This breakdown affected all dialysis patients at the facility, creating what inspectors classified as a "systemic failure" of the facility's dialysis care protocols.
The facility's Executive Director acknowledged during the inspection that the nursing home lacked a comprehensive process to ensure dialysis assessments were completed and properly documented. The director confirmed this gap existed in their communication system with external dialysis centers, which is essential for coordinating care between facilities.
Medical Significance of Dialysis Communication Protocols
Proper dialysis care coordination represents a critical component of kidney failure treatment. Pre-dialysis assessments typically evaluate a patient's fluid status, vital signs, weight changes, and overall clinical condition to determine treatment parameters. Post-dialysis evaluations monitor for complications such as hypotension, cramping, or fluid imbalances that can occur during the filtration process.
Effective communication between nursing homes and dialysis centers ensures continuity of care by sharing vital information about medication changes, dietary restrictions, fluid intake monitoring, and any clinical changes that could affect treatment. Without this coordination, patients face increased risks of complications including cardiovascular stress, electrolyte imbalances, and inadequate toxin removal.
The facility's own policy, titled "Dialysis-Hemodialysis" and revised in 2016, specifically required staff to participate in ongoing communication with dialysis centers using a standardized Dialysis Communication Form filed in residents' medical records. The inspection findings indicate this established protocol was not being consistently followed.
Industry Standards for Dialysis Patient Care
Federal regulations require nursing homes to coordinate care with external healthcare providers to ensure residents receive appropriate treatment. For dialysis patients, this coordination becomes particularly crucial given the complexity and frequency of treatments, which typically occur three times weekly for several hours per session.
Standard practice requires nursing home staff to monitor patients before and after each dialysis session, documenting changes in condition, medication effects, and any concerns that need communication to the dialysis team. This information helps dialysis professionals adjust treatment parameters and identify potential complications early.
The communication breakdown identified at Hearthstone represents a significant deviation from established care standards. When nursing homes fail to maintain proper dialysis coordination protocols, patients may experience medication errors, inappropriate fluid management, or delayed recognition of complications.
Administrative Response and Scope of Impact
When initially confronted with the findings on February 27, the Executive Director reportedly did not understand why the deficient practice constituted substandard quality of care. Inspectors explained that the scope and severity of the violation affected all facility dialysis patients, representing a systematic breakdown rather than isolated incidents.
The facility received a citation under federal regulation F835, which addresses administrative effectiveness in using resources to provide quality care. This violation was classified as causing "minimal harm or potential for actual harm" but affecting multiple residents, indicating inspectors identified the problem before serious patient injuries occurred.
Additional Issues Identified
The inspection revealed that the facility's Dialysis Communication Record system was not being completed correctly, creating gaps in the documentation trail necessary for proper care coordination. Staff were not consistently following the facility's established policy for dialysis patient management, despite having written protocols in place since 2016.
The systematic nature of these failures suggests broader administrative oversight issues in ensuring staff compliance with established healthcare protocols. Federal inspectors noted that effective administration requires facilities to monitor and ensure their care coordination processes function as designed.
This citation highlights the importance of robust quality assurance programs in nursing homes, particularly for residents requiring specialized medical treatments like dialysis. The facility must now develop and implement corrective measures to address these communication and documentation failures while ensuring all dialysis patients receive appropriate care coordination moving forward.
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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