ANAHEIM, CA - A dialysis patient at Anaheim Terrace Care Center experienced multiple transportation failures that resulted in missed and significantly delayed life-sustaining treatments, according to a June 2024 state inspection.
Chronic Transportation Problems Disrupt Critical Care
The resident, who required dialysis treatments twice weekly on Mondays and Fridays, was scheduled for pickup between 3:00-3:30 a.m. to arrive for treatments beginning at 4:15 a.m. However, transportation repeatedly failed to arrive on time or did not show up at all.
On June 7, 2024, transportation was a complete no-show. On June 11, transport arrived at 7:50 a.m. for an 8:00 a.m. appointment to change the resident's dialysis access site, leaving insufficient time to reach the appointment location. The resident was forced to cancel this medical procedure.
Most significantly, on a Friday treatment day, the resident did not receive dialysis until 1:00 p.m.—nearly nine hours later than the scheduled 4:15 a.m. treatment time. This pattern repeated on June 17, when transportation again failed to appear for the scheduled 4:15 a.m. appointment, and the resident received treatment at 1:00 p.m. instead.
Medical Impact of Delayed Dialysis Treatments
Dialysis is a life-sustaining treatment for patients with renal failure. The procedure removes waste products and excess fluid from the blood when the kidneys can no longer perform this function. Consistency in treatment timing is medically important because the body adapts to a regular schedule for fluid and toxin removal.
When dialysis treatments are delayed by several hours, waste products and fluids continue accumulating in the body beyond planned levels. This can lead to fatigue, nausea, and metabolic imbalances. Patients who prepare for early morning treatments by fasting may experience additional complications if forced to wait many hours beyond their scheduled time.
The resident in this case had medical diagnoses including renal failure, diabetes, and high blood pressure—conditions that require careful management and predictable treatment schedules. The combination of skipped meals and delayed dialysis created particular challenges. The resident reported being "exhausted and not hungry" after finally returning from the delayed Friday treatment, having not eaten that day.
Facility Failed to Escalate Problems
Documentation showed the facility was aware of ongoing transportation issues as early as April 2024. An email dated April 19, 2024, specifically instructed facility staff to call the customer service line for the resident's insurance carrier to obtain urgent solutions for transportation problems.
Despite this directive and multiple documented incidents—including no-shows on May 27 and June 7, and late arrivals on June 3 and June 11—facility staff took limited action. The Social Services Director stated that staff had called transportation drivers about the issues but did not escalate concerns to the insurance carrier's customer service department.
When investigators contacted the resident's insurance carrier customer service on June 12, 2024, the representative confirmed that no facility staff member had called to file a grievance regarding the transportation problems.
What Should Have Happened
Standard protocols for facilities managing residents who require off-site dialysis treatments include establishing reliable transportation arrangements and having backup plans in place. When transportation failures occur, facilities should immediately contact the insurance carrier or transportation broker to file formal complaints and request alternative arrangements.
For a resident requiring early morning dialysis at 4:15 a.m., facilities should verify that transportation providers understand the critical nature of these appointments and the medical necessity of on-time arrival. Dialysis appointments cannot simply be rescheduled to later times without medical assessment, as treatment centers operate on strict schedules and patients' physiological needs depend on consistent timing.
The Director of Nursing acknowledged the need for backup transportation but did not demonstrate that such arrangements had been secured despite months of recurring problems.
Resident's Perspective
The resident described the physical toll of the disrupted schedule: "My body was already used to getting dialysis treatments at 4:15 a.m., and it took a lot from my body to try to adjust to getting dialysis at different times." The resident also noted needing transportation staff who could provide physical assistance, as they were unable to walk independently into appointment locations.
After preparing for an early morning treatment by not eating, only to receive dialysis nine hours late, the resident reported missing both breakfast and lunch due to exhaustion and lack of appetite.
Regulatory Finding
State surveyors cited the facility for failing to provide safe, appropriate dialysis care and services. The inspection determined that the facility's failure to follow up on transportation issues with the resident's insurance carrier had the potential for negative health outcomes.
The deficiency was classified as causing minimal harm or potential for actual harm, affecting few residents. However, for the individual resident involved, the impact was significant—missed medical procedures, severely delayed treatments, and physical distress from disrupted care schedules.
Readers can access the complete inspection report through their state's health department website for additional details about this deficiency and the facility's plan of correction.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Anaheim Terrace Care Center from 2024-06-13 including all violations, facility responses, and corrective action plans.
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