Missed Dialysis Treatments Due to Failed Transportation Arrangements
Penalty
Summary
The deficiency involves the facility’s failure to ensure reliable transportation for a resident who required thrice-weekly hemodialysis, resulting in multiple missed treatments. The resident had diagnoses including pulmonary hypertension, type 2 diabetes mellitus, end stage renal disease with dependence on renal dialysis, and required assistance with transfers. Physician orders specified dialysis on Tuesday, Thursday, and Saturday with set chair times and transportation pick-up and return times. The care plan documented that the resident missed dialysis appointments on two occasions due to transportation issues, and progress notes and SBAR forms showed that on three separate dates the resident missed scheduled dialysis because transportation either did not arrive or would arrive too late for the appointment. On at least one occasion, the missed dialysis was attributed to an expired Physician Certification Statement (PCS) form that had not been timely completed and signed by the primary physician, which was required by the resident’s insurance to authorize transportation. Interviews with staff further described the actions and inactions that led to the deficiency. The social services director stated that one missed dialysis treatment occurred because the PCS form had expired and was not completed in a timely manner by the primary physician, and that other missed treatments were due to the contracted insurance transportation not showing up on time. The social services director acknowledged that the resident’s insurance provided transportation based on the PCS certification. The RN supervisor confirmed awareness of at least one missed dialysis treatment and explained that RNs and LVNs process physician orders and work with social services for transportation, noting that some transportation companies fail to show up without warning. The DON stated that the resident had missed a dialysis treatment because transportation did not show. Facility policies on Transportation and Appointments indicated that social services would help residents obtain transportation and that the facility would assist in scheduling appointments and arranging necessary transportation, but the documented events show that these processes did not prevent the resident from missing multiple medically necessary dialysis sessions.
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