Failure to Ensure Timely Transportation for Dialysis Appointments
Penalty
Summary
A deficiency occurred when the facility failed to ensure a resident requiring dialysis was transported to scheduled dialysis appointments as ordered by the physician. The resident, who had end stage renal disease, type 2 diabetes, and vascular dementia, was dependent on staff for mobility and personal care, and required dialysis three times per week. Documentation revealed that the resident missed multiple dialysis appointments due to failures in transportation arrangements and communication among facility staff and the transportation provider. On at least two occasions, the resident missed dialysis appointments. On one occasion, the transportation company did not arrive, and on another, the transportation provider reported that the driver arrived on time but could not locate staff to bring the resident to the lobby, resulting in the resident not being transported. There was conflicting information from staff regarding whether the resident was waiting in the lobby, but no documentation supported that the resident was present and ready for pick-up. The facility's process for notifying and preparing residents for transportation was inconsistent, with some staff unaware of scheduled appointments and others not following established procedures for confirming transportation. As a result of missed dialysis, the resident experienced a decline in condition and required hospitalization for missed dialysis, where she received two sessions of dialysis. Interviews with staff and the resident's family member confirmed that the resident had missed dialysis appointments while at the facility. The facility's policy required arrangements for safe transportation to and from dialysis, but this was not consistently implemented, leading to the deficiency.