Failure to Notify Dialysis Center of Resident Discharge Resulting in Missed Treatment
Penalty
Summary
The facility failed to communicate a resident's ongoing need for dialysis treatment to the receiving provider upon discharge, resulting in the resident missing a scheduled dialysis session. The resident, who had a diagnosis of end stage renal disease and was dependent on renal dialysis, was discharged without the dialysis center being notified of the discharge date or the need to transfer dialysis services. As a result, the resident missed a scheduled dialysis appointment following discharge. Interviews with facility staff revealed inconsistent understanding of responsibility for notifying the dialysis center, with some staff indicating it was the responsibility of the dialysis center or the resident's family, while others acknowledged that the facility's discharge planning policy required social services to coordinate necessary post-discharge care, including contacting community resource providers. Review of the facility's discharge planning policy confirmed that social services or their designee are responsible for scheduling needed care and services at the time of discharge. The lack of communication led to a missed dialysis treatment for the resident.