Failure to Ensure Proper Communication and Transport for Dialysis Care
Penalty
Summary
Licensed nurses failed to follow professional standards of practice for a resident requiring dialysis by not ensuring accurate communication with transport services regarding the correct dialysis center. On one occasion, the resident was transported to the wrong dialysis center, resulting in a delayed start to the dialysis treatment and a reduction in treatment time from three hours to two hours. The facility's records indicated that the resident had a scheduled dialysis regimen, and the error in transportation led to a shortened session. Additionally, there was a lack of communication among licensed nurses about the resident's late transport and decreased dialysis treatment duration. The attending physician was not notified of the shortened dialysis session. Interviews with staff confirmed that key personnel, including the Assistant Director of Nursing, were not informed about the incident or the resident's altered treatment. The facility's policies required the use of at least two patient identifiers and ongoing communication with the dialysis center, but these procedures were not followed in this case.