Failure to Provide Emergency Dialysis Supplies
Penalty
Summary
The facility failed to ensure the availability of necessary emergency supplies for two residents receiving hemodialysis, as required by physician orders and facility policy. Resident 121, who has end-stage renal disease and relies on hemodialysis, was observed to have only one fanny pack containing emergency supplies on her wheelchair, with the second required pack missing from her room. This was confirmed by both the resident and a licensed practical nurse. Similarly, Resident 187, who also depends on renal dialysis, was found to have only one fanny pack on the wheelchair, with the second pack missing from the room, as confirmed by another LPN. The facility's policy mandates that residents with temporary catheters for dialysis must have an emergency protocol kit available at all times, with staff required to check the presence of these kits every shift. The absence of the second fanny pack in the rooms of both residents was confirmed by the Clinical Operations Executive, indicating a failure to comply with physician orders and facility policy. This deficiency placed the residents at risk for delayed emergency intervention in the event of complications related to their dialysis access sites.
Plan Of Correction
1. For Residents #121 and #187, fanny packs with emergency supplies were placed in the resident room and on their wheelchair per National Kidney Foundation and the facility's Care of the Dialysis Resident Policy/Procedure. 2. The DON assessed current in-house hemodialysis residents on 02/05/2025. Current in-house hemodialysis residents had a fanny pack with emergency supplies located both in the resident room and on the resident wheelchair. 3. The Clinical Coordinator or designee will re-educate licensed facility staff regarding the facility's Care of the Dialysis Resident Policy/Procedure requirement for a fanny pack with emergency supplies to always be available in the resident room and on the resident wheelchair. 4. The DON or designee will continue to review current in-house hemodialysis residents weekly to assure compliance regarding the facility's Care of the Dialysis Resident Policy/Procedure requirement for a fanny pack with emergency supplies to be always located both in the resident room and on the resident wheelchair. This weekly review will continue for the next three months. Audit results will be reported to the Quality Assurance Performance Improvement committee monthly for three months to assure continued compliance.