Failure to Ensure Transport and Access to Scheduled Dialysis Treatment
Penalty
Summary
The facility failed to ensure that a resident who required hemodialysis was transported to receive the ordered treatment, resulting in a missed dialysis session. The resident had end stage renal disease and a physician’s order for hemodialysis on Monday, Wednesday, and Friday during the day shift, with instructions that if dialysis was missed for any reason, a BMP lab was to be drawn the following day and reported to the physician. The resident’s care plan identified a need for dialysis three times a week and included an intervention to encourage attendance at scheduled dialysis appointments. The resident was cognitively intact, with a BIMS score of 15, and routinely received dialysis. On the day of the incident, the resident was scheduled for an earlier-than-usual 5:00 AM dialysis time to accommodate an afternoon appointment, and the on-site dialysis center was reported to be full, requiring residents to be switched around. A night-shift CNA began preparing the resident for dialysis and placed her on a bedpan but did not return, leaving the resident unattended until day-shift staff arrived. By the time day-shift staff and the LPN became involved, night shift reported they were unable to find a dialysis chair for the resident, and the dialysis unit had no available chair later in the day, resulting in the resident missing the scheduled dialysis treatment. The DON reported that a night-shift CNA had called about not being able to locate a dialysis chair and was instructed to search the facility, dialysis area, and room and get the resident to dialysis, but the resident ultimately did not receive the ordered dialysis session.
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