Failure to Provide Emergency Kits for Dialysis Residents
Penalty
Summary
The facility failed to provide emergency kits at the bedside for two residents who required dialysis and had a dialysis fistula or shunt. Both residents had diagnoses including diabetes mellitus type 2 and end stage renal disease, and were dependent on renal dialysis. Their care plans and physician orders indicated the presence of a fistula or shunt and the use of anticoagulant medications, which increased their risk for bleeding. Despite these documented risks, observations confirmed that neither resident had an emergency kit at their bedside, as verified by interviews with licensed nursing staff. The absence of the emergency kits was acknowledged by the nursing staff, who stated that the kits were necessary to manage potential bleeding from the dialysis access sites. The Director of Nursing also confirmed that the lack of emergency kits placed the residents at risk for continuous bleeding from their dialysis fistulas. The deficiency was identified through a combination of record review, direct observation, and staff interviews.