Failure to Ensure Scheduled Hemodialysis Leading to Resident Harm
Penalty
Summary
The facility failed to ensure that a resident with end stage renal failure received scheduled hemodialysis (HD) treatments as ordered. The resident was admitted and readmitted with a diagnosis requiring regular HD, but missed all scheduled treatments since admission. Interviews with collateral contacts and the resident revealed that the facility did not notify the resident’s representatives about missed HD sessions, nor did they attempt to accommodate the resident’s need for a closer HD center or a bed during treatment, despite repeated requests. The resident was unable to tolerate sitting for extended periods due to weakness and repeatedly communicated these needs to facility staff, but no action was taken to change the HD center or transportation arrangements. Facility staff, including the physician assistant, social worker, business office manager, and unit manager, were unaware that the resident had missed all HD treatments until notified by the HD center or after the resident was hospitalized. There was no documentation of the resident’s preferences, reasons for missed appointments, or any risk and benefit discussions with the resident or their representative. Additionally, there was no evidence of notification to the provider, resident representative, or facility management regarding missed HD treatments, nor was there documentation of ongoing monitoring or medical management for the resident’s condition due to missed treatments. Review of the resident’s care plan and progress notes showed a lack of interventions addressing the resident’s preferences, coordination with the HD center, or follow-up for missed treatments. The care plan did not include a focus area for missed HD treatments, and progress notes failed to document arrangements for rescheduled sessions or monitoring of the resident’s condition. The resident ultimately experienced harm, requiring hospitalization in the intensive care unit for volume overload and heart failure, conditions attributed to missed HD treatments.