Failure to Ensure Timely Dialysis Due to Transportation and Communication Errors
Penalty
Summary
A deficiency occurred when a resident with end stage renal disease (ESRD), who required hemodialysis three times a week, missed a scheduled dialysis session due to a transportation issue and miscommunication between the facility and the dialysis center. The resident was admitted with orders to continue dialysis on specific days, but the nursing staff did not obtain the physician's order for dialysis and transportation until several days after admission. As a result, the resident went four days without receiving dialysis, and attempts to reschedule the missed session were unsuccessful due to lack of available openings at the dialysis center. The resident was transported to the dialysis center on a day when no appointment was scheduled, resulting in a return to the facility without treatment. The lack of clear responsibility for booking transportation, with confusion between nursing staff and the resident's family, contributed to the missed treatment. When the resident finally arrived for the next scheduled dialysis session, they were found to be unstable, confused, and lethargic, necessitating transfer to the hospital emergency department. The facility's own policy required nursing staff to arrange transportation and ensure care according to recognized standards, which was not followed in this case.