Dialysis Transportation, Assessment, and Documentation Failures
Penalty
Summary
The deficiency involves multiple failures to coordinate and document transportation and clinical care for residents receiving dialysis and specialty appointments. For one resident with ESRD on hemodialysis, the facility’s transportation arrangements to and from the dialysis clinic were not properly coordinated. On one dialysis day, the contracted transportation left because the resident’s treatment was not yet complete, and the resident was not picked up from the clinic. The resident, who had muscle weakness, difficulty walking, and an ileostomy, reported walking to a nearby restaurant, emptying his ostomy bag, taking two public buses, stopping at a bank, and then walking the remaining distance back to the facility, including crossing major intersections. Staff interviews confirmed ongoing transportation issues for this resident, including prior occasions when transportation left the resident at the clinic and a family member had to pick him up. The facility also failed to assess, document, and notify the physician when this resident returned to the facility approximately seven to eight hours after dialysis. There was no documentation of the resident’s clinical condition, no change-of-condition assessment, no progress notes, and no monitoring despite the resident reporting fear, anxiety, and crying related to being followed by a man and involving the police while returning by public transit. Nursing staff acknowledged that the resident’s symptoms of being tired, weak, fearful, and crying constituted a change of condition and that the physician was not notified. The DON and DSD verified there was no assessment upon arrival, no physician notification of the incident, and no documentation of the resident’s status at the time of return. The facility further failed to provide timely psychosocial support and timely medication management for this resident. The resident’s PRN lorazepam for anxiety had been discontinued the day before the incident and was not available on the day the resident reported fear, anxiety, and crying; it was reordered the following day and first administered two days after the incident. There was no documented social services follow-up with the resident on the day of the incident, and the SSD confirmed she had not spoken with the resident until the following day. Additionally, the resident’s midodrine, ordered three times daily with meals for hypotension, was administered significantly late on one dialysis day, outside the facility’s one-hour window, and the physician was not notified of the late administration. Another resident experienced a failure in transportation coordination for a dermatology appointment. This resident had a documented brown scalp lesion and a dermatology consultation scheduled, which was rescheduled to a later date. Nursing notes showed the appointment was moved, and social services notes later documented that transportation did not arrive for the rescheduled appointment, requiring another rescheduling and arrangement of private transportation. Staff interviews indicated that alternative transportation options such as private ride-share and CNA accompaniment were available, but there was no evidence that all transportation methods were exhausted before rescheduling the earlier appointment, despite having time to arrange alternatives. The facility also failed to document departure and arrival times for two residents who regularly left the facility for outpatient dialysis. For one resident, progress notes for multiple dialysis dates lacked documentation of either departure time, arrival time, or both. For the second resident, treatment records showed multiple dialysis sessions, but corresponding progress notes were missing departure and/or arrival times on numerous dates. The DSD stated that nurses were responsible for documenting residents’ departure and arrival times in progress notes, and the DON confirmed that this documentation was missing for the identified dates.
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