Missed Dialysis Appointment Due to Insufficient Staffing
Penalty
Summary
A deficiency occurred when a resident who was dependent on dialysis did not receive a scheduled dialysis treatment due to insufficient staffing. The resident, who was alert, oriented, and dependent on staff for activities of daily living, required hemodialysis three times a week as ordered by her physician and documented in her care plan. On the date in question, there was no documentation in the resident's medical record or pre- and post-dialysis treatment forms indicating that dialysis was provided. Interviews with facility and dialysis staff confirmed that the resident missed her dialysis appointment because there were not enough staff available to get her out of bed and transport her to the in-house dialysis unit. The dialysis nurse reported that the CNA assigned to the resident was unable to assist due to a migraine, and no other staff were available to provide the necessary transport. Despite attempts by dialysis staff to coordinate with facility staff, the resident was not brought to her appointment, and the dialysis treatment was missed. Further review revealed discrepancies in documentation, as the Medication and Treatment Administration Record indicated the resident attended dialysis, but this was later confirmed to be inaccurate by the Director of Nursing and dialysis staff. The facility's agreement with the dialysis provider specified that the facility was solely responsible for transporting residents to and from dialysis at scheduled times, and missing or late arrivals could result in missed treatments. The deficiency was substantiated by interviews, record reviews, and facility policy.