Failure to Ensure Reliable Dialysis Transportation Resulting in Missed Treatments and Hospitalizations
Penalty
Summary
The facility failed to provide safe and appropriate dialysis care and services for two residents who required dialysis three times weekly for end-stage renal disease (ESRD). Both residents experienced missed dialysis sessions due to unreliable transportation arrangements, which resulted in avoidable hospitalizations for complications such as volume overload and severe hyperkalemia. The residents' care plans identified risks related to transportation issues, but interventions were not effectively implemented to prevent missed treatments. One resident, with diagnoses including hypertensive chronic kidney disease, ESRD, and moderate cognitive impairment, had a physician's order for dialysis three times a week. Despite a care plan addressing transportation risks, the resident missed multiple dialysis sessions and was hospitalized twice for complications directly related to missed treatments. The medical record documented symptoms such as shortness of breath and elevated potassium levels, leading to ICU admission and further hospital stays. Another resident, with diagnoses including type 2 diabetes, chronic pulmonary edema, hypertension, anemia in chronic kidney disease, hyperlipidemia, hyperkalemia, and ESRD, also had a physician's order for regular dialysis. This resident missed several dialysis appointments due to transportation failures, resulting in hospital admission for hyperkalemia. Interviews with facility staff revealed a lack of clear responsibility and coordination for arranging dialysis transportation, with confusion over which department was accountable. The facility relied on a state-funded transportation company with a difficult and antiquated appointment process, and there was no proactive system to ensure residents attended their dialysis appointments.