Failure to Notify and Reschedule Missed Dialysis Appointments
Penalty
Summary
The facility failed to ensure safe and appropriate dialysis care for a resident dependent on hemodialysis by not notifying the dialysis center when the resident missed scheduled treatments due to transportation issues, and by not rescheduling missed appointments as requested by the dialysis center. The resident, who had end stage renal disease, anemia, and an amputation, was scheduled for hemodialysis three times per week per physician orders. On two consecutive occasions, the resident missed treatments because the transportation company did not pick up the scheduled rides, despite the resident being ready and waiting at the designated times. The scheduler confirmed that the transportation company failed to provide the rides, and that the resident had not refused transportation. The Director of Nursing Services (DNS) and other staff were informed of the missed rides, but the facility did not notify the dialysis center of the missed appointments. The dialysis center nurse reported that the facility did not communicate about the missed treatments and did not arrange for make-up sessions, even though the center had requested rescheduling. Clinical records showed that after missing the second treatment, the resident experienced elevated blood pressure and blood sugar levels, prompting physician notification and orders for lab work. The facility's policy required timely arrangement of transportation and communication of issues affecting the resident's care plan, but these steps were not followed in this instance, resulting in missed dialysis treatments and lack of coordination with the dialysis center.