Failure to Provide Required Emergency Dialysis Supplies at Bedside
Penalty
Summary
The facility failed to provide necessary emergency equipment and supplies at the bedside for a resident receiving hemodialysis, as required by professional standards and the facility's own policy. The resident, who had end stage renal disease and was dependent on renal dialysis, did not have an emergency kit containing clean gauze, a tourniquet, and tape at the bedside to manage potential bleeding from an AV shunt. This was confirmed during observations and interviews with nursing staff, who acknowledged the absence of the kit and its importance in managing emergencies such as bleeding from the AV fistula. Record review showed that the resident had active physician orders to monitor the AV shunt site for signs of infection, edema, and bleeding, and to apply pressure and notify medical staff if bleeding occurred. Despite these orders and the facility's policy requiring staff to be trained and prepared for dialysis-related emergencies, the necessary emergency kit was not present at the resident's bedside. Interviews with nursing staff and the DON confirmed that the kit should have been available and that its absence could delay emergency care.