Failure to Provide Timely Transportation for Dialysis Resulting in Shortened Treatments
Penalty
Summary
The facility failed to ensure that a resident requiring hemodialysis was transported in a timely manner to receive the full duration of prescribed dialysis treatment. The resident, who had a diagnosis of End Stage Renal Disease and a physician's order for dialysis three times a week at a specified chair time, consistently arrived late to her appointments. Interviews and record reviews revealed that the resident's late arrivals occurred on multiple occasions over the previous month, resulting in shortened dialysis sessions. The dialysis Nurse Manager confirmed that the resident's average arrival time was significantly later than scheduled, and that the clinic had to adjust her chair time, which sometimes led to early termination of treatment due to the clinic's closing time. Contributing factors included unclear communication regarding chair time changes between the dialysis clinic and the facility, as well as transportation issues such as facility vans being out of service and reliance on an external transport provider with a history of tardiness. The resident expressed frustration with the repeated changes and late arrivals, noting the impact on her treatment schedule. Staff interviews confirmed awareness of the transportation challenges and the expectation that residents be transported on time, but documentation showed that the resident continued to experience delays and incomplete dialysis sessions.