Failure to Provide Timely Dialysis Due to Transportation Breakdown
Penalty
Summary
A deficiency occurred when a facility failed to ensure that a resident dependent on dialysis received scheduled dialysis treatments. The resident, who had diagnoses including end stage renal disease, chronic diastolic heart failure, and dependence on renal dialysis, was admitted with a care plan specifying the need for regular dialysis to avoid complications. Despite this, the resident missed multiple dialysis appointments due to the facility's transportation van being out of service and the inability to secure alternative transportation. Documentation and interviews revealed that the resident missed dialysis sessions on several occasions, resulting in at least one hospital admission for dialysis and pulmonary venous congestion. The facility's progress notes and staff interviews confirmed that the transportation van was broken for approximately one and a half weeks, during which time the resident was unable to attend scheduled dialysis treatments. Attempts to arrange alternative transportation were unsuccessful, as local companies either did not operate early enough or did not service the area. The resident was sent to the hospital twice; on one occasion, dialysis was not provided, and on another, the resident was admitted overnight to receive dialysis. The dialysis center and hospital staff confirmed that the resident had not received dialysis for an extended period due to transportation issues. The facility's own policy required assistance in obtaining transportation for necessary medical services, but this was not achieved, resulting in missed life-sustaining treatments. The resident expressed awareness of the missed treatments and the importance of dialysis, and laboratory findings indicated a need for ongoing dialysis.