Failure to Ensure Safe Dialysis Transportation and Communication
Penalty
Summary
Facility staff failed to ensure a resident requiring dialysis received appropriate transportation and ongoing communication and collaboration with the dialysis center. The resident, who was non-weight bearing due to wounds and osteomyelitis and had multiple comorbidities including end-stage renal disease, repeatedly missed dialysis appointments because the transportation provided was not suitable for his height and high-backed wheelchair. Despite the resident's repeated complaints to staff about the inadequacy of the vehicles, no measurements were taken to validate his concerns until after multiple missed appointments. Staff and leadership characterized the missed appointments as refusals, but documentation and interviews revealed the resident was willing to attend dialysis if appropriate transportation was provided. The facility also failed to maintain effective communication with the dialysis center regarding the resident's care. The communication book sent with the resident to dialysis was largely incomplete, with only vital signs recorded and no documentation of medications administered, lab results, or other pertinent information. The facility did not consistently receive or document lab results or medication administration from the dialysis center, and there was no evidence of proactive follow-up by facility staff to obtain this information. The DON acknowledged that the expected process for communication and documentation was not followed. Additionally, the facility's own policies required coordination of transportation and communication with outside providers, but these procedures were not adhered to. The lack of proper transportation arrangements and incomplete communication with the dialysis center led to missed treatments and gaps in the resident's clinical record, including missing lab results and medication documentation. These failures persisted until the resident was finally measured and appropriate transportation was arranged, but not before multiple missed dialysis sessions and incomplete clinical information.