Failure to Provide Safe and Appropriate Transportation for Dialysis
Penalty
Summary
The facility failed to ensure that a resident received necessary care and services in accordance with her comprehensive assessment and professional standards of practice by not conducting a comprehensive interdisciplinary assessment of her transportation needs for dialysis appointments. The resident, who had end stage renal disease, type 2 diabetes, and a recent amputation of two toes, required substantial to maximal assistance with transfers and was dependent on a wheelchair for mobility. Despite these needs, the facility arranged for her to be transported to dialysis appointments via Uber, which required unsafe and uncomfortable transfers from her wheelchair to a standard vehicle three times a week. Documentation and interviews revealed that the resident missed or experienced delays in dialysis appointments due to transportation issues, including the facility's failure to pay for appropriate wheelchair van services and the subsequent use of Uber. The resident expressed discomfort and fear regarding the Uber transportation, stating that the cars were difficult to enter and exit, and that she was transferred by staff in a manner that was physically challenging and unsafe. Staff, including CNAs and nurses, reported difficulties in transferring the resident and acknowledged that Uber was not an appropriate mode of transportation for her condition. The facility's own rehabilitation department was not consulted to assess the resident's transportation needs prior to the decision to use Uber. As a result of these actions and inactions, the resident sustained actual harm, including a right chest-wall hematoma, soft-tissue swelling, and possible rib fractures after being transported in a standard vehicle. The unsafe transportation practice continued even after the injury, with the resident being exposed to further risk of harm. The facility's failure to provide safe and appropriate transportation, as well as the lack of interdisciplinary assessment and communication, directly led to the resident's injuries and missed or delayed dialysis treatments.
Removal Plan
- Resident 1 was assessed by assigned licensed nurse for any adverse effects of being transferred to dialysis using Uber Health transportation.
- Resident 1 was assessed by PT to determine whether Resident 1 can tolerate the car or wheelchair van transportation.
- The Care Plan was updated to reflect current transportation information for dialysis.
- A new contract for wheelchair transport was drawn up by the ADM.
- An ad hoc QAPI Committee meeting was held to discuss changes in contracted dialysis transportation services.
- Inservice training was conducted by DON and/or DSD with licensed staff regarding use of contracted dialysis transportation.