Failure to Arrange Transportation Resulting in Missed Dialysis Treatments
Penalty
Summary
The facility failed to provide transportation for a resident requiring scheduled dialysis treatments, resulting in missed dialysis sessions. The resident was admitted with diagnoses including acute kidney failure, dependence on renal dialysis, and metabolic encephalopathy. The resident’s care plan dated 11/22/25 documented that dialysis was to occur three days a week on Tuesday, Thursday, and Saturday, with transportation to the dialysis center to be provided and the resident to remain free from complications secondary to requiring dialysis. Progress notes showed the resident received dialysis at the hospital on 12/24/25 and did not receive treatment on 12/25/25, and there was no documentation of dialysis treatment on 12/27/25. In interviews, the receptionist stated that she or nursing staff assist with dialysis transportation planning and reported she was unable to set up the resident’s dialysis transportation over the December holiday. A family member reported receiving a call from the dialysis center asking why the resident was not present for dialysis and stated the resident was very sick and had not been admitted in that condition. The family member went to the facility and requested that staff send the resident to the ER for dialysis, which was completed on 12/29/25. An LPN stated that evening shift staff had informed her that the resident’s transportation to dialysis needed to be scheduled and confirmed the resident missed the dialysis treatment that was supposed to occur on 12/27/25. The DNS acknowledged that the resident missed dialysis due to transportation not being scheduled.
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