Failure to Ensure Transportation for Dialysis Appointment
Penalty
Summary
A resident with a diagnosis of End Stage Renal Disease, requiring hemodialysis three times weekly, missed a scheduled dialysis treatment due to a failure in transportation arrangements. The resident's clinical records and progress notes confirmed that the resident did not attend the scheduled dialysis session because the transportation service did not arrive to pick up the resident. Interviews with nursing staff revealed that the transportation company was not notified when the resident was not picked up, and staff were either unaware of the missed pickup or did not follow the facility's practice of contacting the transportation provider to determine the cause. The Director of Nursing confirmed that the expectation was for nurses to notify the transportation company in such situations, but this was not done. Review of the facility's policy indicated that the facility is responsible for helping arrange transportation for residents as needed. The failure to ensure transportation resulted in the resident missing a critical dialysis treatment.