Failure to Arrange Timely Transportation Resulting in Missed Dialysis
Penalty
Summary
The facility failed to ensure timely and appropriate hemodialysis care for a resident with end-stage renal disease, resulting in missed dialysis treatments. The resident, who had moderate cognitive impairment and a physician's order for scheduled dialysis three times per week, did not receive dialysis on at least one occasion due to transportation not being arranged. Documentation in the nurse's notes confirmed that the missed treatment was due to the transport company not arriving, and interviews with facility staff revealed that transportation should have been pre-arranged and followed up, especially after the resident's readmission. Interviews with the Social Service Director, an LVN, and the Director of Nursing confirmed that the facility's policy required pre-arrangement and follow-up of transportation for dialysis appointments. The facility's transfer agreement also specified responsibility for arranging suitable transportation, including necessary equipment and personnel. The failure to arrange transportation as required by policy and agreement led directly to the resident missing scheduled dialysis treatments while at the facility.