Failure to Provide Dialysis Emergency Kit at Bedside
Penalty
Summary
The facility failed to ensure that a resident requiring hemodialysis had a dialysis emergency kit (E-kit) at the bedside, as required for immediate intervention in case of complications such as unexpected bleeding from the hemodialysis access site. Observation and interview confirmed that the resident, who had diagnoses including end stage renal disease, hydronephrosis, and dependence on hemodialysis, did not have an E-kit available at the bedside. The resident's care plan specified the need for immediate intervention for dialysis-related complications, and the Director of Nursing confirmed that all dialysis residents should have an E-kit readily accessible. The deficiency was identified during a review of the resident's records, care plan, and through direct observation and staff interviews. The resident was noted to have moderately impaired cognition and required varying levels of assistance with daily activities. The facility's policy and procedures indicated the need for immediate action and supplies in the event of bleeding from the dialysis access site, but these supplies were not present at the resident's bedside at the time of the survey.