Failure to Review Updated Dialysis Transportation Results in Missed Treatment
Penalty
Summary
A registered nurse failed to review and act upon a change in the transportation method for a resident dependent on hemodialysis, resulting in the resident missing a scheduled dialysis session. The resident, an older adult with multiple complex medical conditions including end stage renal disease, osteomyelitis, heart disease, diabetes, and a stage 4 pressure ulcer, was typically transported to dialysis via gurney due to early morning appointments and personal preference. However, after a change in insurance and transportation arrangements, the Director of Social Services scheduled wheelchair transport and communicated this change through the facility's electronic medical record system. On the day of the scheduled dialysis, the nurse on duty did not review the updated communication regarding the new wheelchair transport arrangement. When the transportation staff arrived with a wheelchair instead of a gurney, the nurse was unaware of the change and the transport staff left without the resident. Subsequent attempts to contact the transportation company were unsuccessful, and the resident ultimately missed the dialysis session. The resident was then sent to a general acute care hospital, where dialysis was not provided because the resident had already received treatment the previous day during a prior hospital visit. The facility's policy required that all pertinent information regarding dialysis care, including transportation details, be documented and available to all caregivers. Despite this, the failure to review and act on the updated transportation method led to a missed dialysis session and unnecessary hospital transfer for the resident.