Failure to Provide Appropriate Emergency Response for Dialysis Catheter Bleed
Penalty
Summary
The facility failed to provide appropriate monitoring, emergency response, and staff intervention for a resident receiving hemodialysis, resulting in actual harm. The resident, who had end stage renal disease and a central venous catheter (CVC) for dialysis, was found by an LPN with her catheter leaking blood from the red port, with blood flowing onto the floor and down her chest. The LPN clamped the line but left to obtain a cap, during which time the clamp became unclipped and bleeding resumed. The resident was then escorted down the hallway by a CNA without continuous licensed nurse supervision of the access site. Subsequently, the resident was found in her room slumped on the bed, with blood continuing to leak from the catheter, followed by loss of consciousness, absent respirations, and pulse. CPR was initiated, and EMS was called, but the resident was later pronounced deceased at the hospital after extensive interventions. The investigation revealed that the facility did not provide evidence of staff training or competency in responding to dialysis access emergencies. The Director of Clinical Services confirmed that no such training had been provided and that staff were expected to rely on their initial licensing preparation. The nurse involved did not apply a hemostat when the clamp failed and did not replace the cap on the CVC, contrary to best practices and facility policy. These failures were inconsistent with professional standards of practice, the resident's care plan, and the facility's own policies regarding monitoring and responding to changes in condition.