Missed Dialysis Treatments Due to Unreliable Transportation
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents requiring dialysis received services consistent with physician orders and professional standards of practice, specifically due to inadequate and unreliable transportation to scheduled dialysis treatments. One resident with ESRD, dependence on renal dialysis, and type 2 DM with neuropathy was ordered to receive dialysis on Monday, Wednesday, and Friday. Nursing documentation showed this resident did not attend dialysis on a scheduled Monday because the transportation company failed to arrive, with the last completed dialysis session occurring the prior Friday. The following day, a change in condition note documented abdominal distension and fluid overload attributed to the missed dialysis appointment due to lack of transportation, with a recommendation to send the resident to the hospital. Hospital records indicated the resident presented with missed dialysis due to arranged transport missing the scheduled pick-up, reporting abdominal fullness and shortness of breath from volume overload. The exam and labs showed abdominal distension and significantly elevated potassium, BUN, and creatinine, and the assessment identified hyperkalemia due to missed dialysis, requiring urgent dialysis. Another resident with ESRD, dependence on renal dialysis, type 2 DM with neuropathy, and polyneuropathy had multiple documented missed dialysis sessions because transportation failed to arrive. Nursing notes showed missed dialysis on several occasions, with one missed session followed by hospital transfer after the resident developed fever, chills, shaking, no urine output for two days, and body swelling. Provider notes linked the acute deterioration, including fever, hypertension, hypoxia, and worsening confusion, to a missed dialysis session. Hospital records documented emergent dialysis in the ED for hyperkalemia from a missed dialysis appointment due to transportation issues and admission for acute metabolic encephalopathy likely due to missed dialysis and sepsis, most likely from pneumonia. Interviews with the DON, scheduler, UM, and MD confirmed that insurance-based transportation was required to be used first, was unreliable, frequently failed to show, and that residents, including these two, missed dialysis appointments and were hospitalized after missed treatments.
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