Failure to Provide Required Lift Pad Results in Missed Dialysis Appointment
Penalty
Summary
A resident with muscle weakness, diabetes, and dependence on renal dialysis was admitted to the facility and required extensive assistance for transfers, including the use of a lift pad on dialysis days as ordered by the physician. The resident's Kardex and physician orders specified that a lift pad must be placed under the resident on dialysis days (Monday, Wednesday, and Friday). On the date in question, the resident was sent to her dialysis appointment without the required lift pad, resulting in her missing the scheduled treatment. Interviews with the resident, her representative, dialysis staff, and the transport company manager confirmed that the absence of the lift pad prevented the dialysis center from transferring the resident for treatment, and the resident had to be sent to the hospital for dialysis instead. This issue was reported as having occurred multiple times previously. Further investigation revealed that the nurse aide responsible for preparing the resident for the appointment was unaware of the need for a lift pad and did not place it under the resident. The Director of Nursing acknowledged that nursing staff were responsible for ensuring the lift pad was in place for dialysis appointments and confirmed that the resident was not a total lift for transfers within the facility but required a total lift at the dialysis center. The failure to send the lift pad as required by physician orders and care plan led directly to the resident missing her dialysis treatment.