Failure to Coordinate Dialysis Transportation Leading to Prolonged Post-Treatment Waits
Penalty
Summary
The deficiency involves the facility’s failure to ensure appropriate coordination of transportation for a resident who required thrice-weekly hemodialysis. The resident, who had end stage renal disease requiring dialysis, hypertension, and a history of repeated falls, was admitted and re-admitted to the facility and was cognitively able to express needs and understand information. The resident used a walker or wheelchair and required substantial/maximal assistance with several ADLs. Documentation from the hemodialysis flowsheet showed that on 1/7/2026, the resident’s dialysis treatment ran from 10:48 a.m. to 2:56 p.m., but an Uber receipt from the hemodialysis center indicated the resident was not picked up until 5:29 p.m. and did not arrive back at the facility until 6 p.m. A hemodialysis social worker note stated that on that date the resident experienced long wait times after treatment, was not picked up by the arranged transportation, and the hemodialysis administrator had to assist with arranging Uber transportation back to the facility. Interviews and record review showed that the facility’s social services did not ensure that transportation pick-up times from the hemodialysis center were properly arranged or communicated. The Social Services Director (SSD) reported that the resident had ongoing problems with dialysis transportation related to insurance, including transportation arriving too early while the resident was still receiving treatment, but the SSD could not provide documentation of follow-up with the transportation agency. The resident reported that transportation during dialysis days often arrived too early, too late, or not at all, and stated he had waited three hours after dialysis for pick-up, feeling tired, weak, hungry, and ignored. The hemodialysis social worker indicated the problem could be that the facility did not inform transportation to arrange a pick-up time aligned with the end of treatment. Review of a document containing the resident’s insurance, dialysis schedule, and transportation information showed it listed only the pick-up time from the facility to the dialysis center and did not include a return pick-up time from the dialysis center. The SSD acknowledged that the flyer lacked a return pick-up time and that waiting for late or unarranged transportation would not make the resident feel good. The facility’s transportation policy stated that social services should help residents arrange needed transportation and that transportation concerns should be referred to social services.
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