Failure to Provide Dialysis Emergency Kit at Bedside
Penalty
Summary
The facility failed to provide a dialysis emergency kit (e-kit) at the bedside for a resident who required hemodialysis. The resident, admitted with chronic kidney disease requiring hemodialysis, anemia, and hypertension, had physician orders for hemodialysis three times a week and a care plan identifying a high risk for bleeding. The care plan specifically required that an e-kit be available at all times to manage potential bleeding events. Multiple observations on different occasions confirmed that there was no e-kit present in the resident's room, either pinned to the wall, on the nightstand, or inside the bedside drawer. The resident also confirmed not having seen an e-kit in the room. Interviews with staff, including an LVN and the DON, confirmed that the e-kit should always be at the resident's bedside and checked daily to ensure it is stocked. The facility's policy required ongoing assessment and oversight for residents receiving hemodialysis, including monitoring for complications and implementing appropriate interventions. Despite these requirements, the absence of the e-kit at the bedside represented a failure to follow the care plan and facility policy for providing safe and appropriate dialysis care.