Failure to Timely Remove Dialysis Pressure Dressing and Assess Access Site
Penalty
Summary
A resident who required dialysis returned to the facility with a pressure dressing still in place on their left forearm fistula after a morning dialysis session. The resident reported that the nurse typically removes the dressing after returning from dialysis. However, observations revealed that the pressure dressing remained on the resident's arm into the following morning. The resident stated that the dressing had been removed the previous night but was reapplied by the night shift nurse due to continued bleeding. The pressure dressing was not removed until late the next morning, after it was brought to the attention of the registered nurse, who had not been informed by the night shift about the status of the dressing and had not yet assessed the access site due to the resident's early appointment. The Director of Nursing confirmed that the pressure dressing should be removed a few hours after dialysis and the access site checked for bleeding every shift, unless there are specific physician orders to leave the dressing on. The dialysis provider advised that if bleeding is present, the dressing may remain for a couple of hours but should be assessed every two to three hours and removed once bleeding stops. The failure to remove the pressure dressing in a timely manner and to properly communicate and assess the access site led to the deficiency.