Failure to Update Care Plan for Dialysis Transportation Needs
Penalty
Summary
The facility failed to develop and revise a comprehensive, person-centered care plan to address the transportation needs of a resident who required dialysis. After the resident's transportation method was changed from a wheelchair-accessible van to a standard vehicle (Uber), there was no interdisciplinary assessment or update to the care plan to reflect this significant change. The change in transportation was made without discussion or involvement of the resident or her family, and there was no documentation of their participation in the care planning process. The care plan did not include interventions for transportation to dialysis, transfer assistance, or mobility safety, and was not revised after the transportation method changed or after the resident sustained an injury. The resident had a history of foot surgery and was not supposed to put pressure on her feet, requiring a lifted van for safe wheelchair transfer. Despite this, the facility arranged for transportation via Uber, which did not accommodate her functional limitations. The decision to switch transportation providers was made by the corporate office due to payment issues, and the staff responsible for social services and case management did not communicate this change to the resident or her family. As a result, the resident was transported in an inappropriate vehicle, leading to missed dialysis treatments, hospitalization, and physical injury.