Failure to Assess and Monitor Dialysis Resident Post-Treatment Resulting in Fatal Hemorrhage
Summary
A deficiency occurred when a resident with end-stage renal disease, anemia, atrial fibrillation, and a history of removing her own dialysis access site dressing was not properly assessed or monitored upon return from an outpatient hemodialysis treatment. The resident was prescribed Eliquis, increasing her risk for bleeding, and had documented prior incidents of prematurely removing her AV fistula dressing, resulting in bleeding. Despite these known risks and care plan interventions requiring monitoring of the access site and leaving the dressing in place for at least four hours post-dialysis, staff failed to conduct a post-dialysis assessment or monitor the resident for complications upon her return. On the day of the incident, the resident returned to the facility at approximately 7:10 p.m. after hemodialysis. The assigned RN assisted the resident to her room but did not visually inspect the AV fistula site, check vital signs, or document the resident's return. The RN assumed the site was not bleeding because the resident's clothing was not wet and did not notify other staff of the resident's return. Both the LVN and CNA assigned to the resident were on their lunch breaks and were not informed of the resident's return. No staff member was designated to receive or assess the resident upon her arrival, and there was no documentation of a post-dialysis assessment in the medical record. Approximately 40 minutes later, the CNA discovered the resident unresponsive, with the AV fistula dressing removed and active bleeding from the site. Blood was found on the bed, floor, and the resident's clothing. Emergency measures were initiated, but the resident was pronounced deceased by paramedics. Interviews and record reviews confirmed that facility staff did not follow established policies and procedures for post-dialysis assessment, monitoring, and documentation, nor did they implement the resident's care plan interventions for AV fistula care and monitoring.
Removal Plan
- The DON conducted a comprehensive review of Resident 1's hemodialysis-related care upon Resident 1's return from the hemodialysis treatment, including interviews with RN 1 and LVN 1, review of facility's P&P on Dialysis Care, forms used for dialysis care, nurses progress notes, and communication related to Resident 1's return from dialysis treatment, identifying failures related to post-dialysis assessment, monitoring, communication, and documentation.
- All residents returning from hemodialysis treatment or any off-site procedure will be assessed upon return at the soonest practicable time by the Charge Nurse and/or RN, including direct inspection of the hemodialysis access site, vital signs, bleeding assessment, condition of the resident, documentation of findings in the nursing progress notes, and the Nursing Facility Post Dialysis Assessment form. CNA will immediately notify any licensed nurse of any observed signs of bleeding or distress and will endorse findings to the LVN Charge Nurse and/or RN.
- The DON and Medical Records staff conducted an audit on the Nursing Facility Pre and Post Dialysis Assessment forms for eight residents receiving hemodialysis treatment, finding no other residents with deficiencies similar to those found for Resident 1.
- The Administrator and the DON reviewed and updated the P&P on Dialysis Care. The Dialysis Flow Sheet-Return Assessment form was updated to include signature columns for the Charge Nurse and RN Supervisor, as well as the inclusion of the Nursing Facility Pre and Post Dialysis Assessment form. The updated policy became effective and will be presented to the Quality Assurance Committee at the next monthly meeting.
- The Administrator notified the Medical Director regarding the details of the IJ issued by the SSA and the updated policy on Dialysis Care.
- The DON provided one-on-one in-service to RN 1 and LVN 1, who were assigned to Resident 1 during the 3 p.m. to 11 p.m. shift regarding P&P on Dialysis Care, focusing on conducting pre and post dialysis assessments, assessing the dialysis access site for signs of bleeding, resident's medical condition and other complications, and documentation requirements.
- The facility will ensure that residents who require hemodialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.
- The DON and DSD provided in-service education to nursing staff regarding the updated policy on Dialysis Care, with emphasis on comprehensive assessment and monitoring of residents by LVNs or RNs post dialysis treatment, completion of the Nursing Facility Post-Dialysis Assessment form, the Dialysis Flow Sheet-Return Assessment, and nursing progress notes documenting the date and time residents return to the facility.
- The DON performed a competency check of RN 1 regarding dialysis care, including monitoring, documentation, and communication.
- The DON performed competency checks of licensed nurses regarding post dialysis observation, reporting, monitoring, interventions, and proper documentation.
- The DSD performed competency checks of CNAs regarding observation and reporting on resident's return post-dialysis and post procedure, monitoring, safety, and communication of observations.
- The DON conducted an audit on residents who returned from hemodialysis, showing all requirements were completed and in place for each of the reviewed residents, and that a process is in place to ensure appropriate assessment, monitoring, documentation, and clinical oversight for residents returning to the facility following outpatient hemodialysis.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Incomplete Dialysis Communication Records: The facility failed to maintain ongoing communication and collaboration with the dialysis provider for two residents receiving HD. For one resident with ESRD and hemiplegia, and another resident with CKD and rib fractures, dialysis communication forms were left incomplete and unsigned on multiple occasions, including sections for pre-transfer and post-return information. An HD RN reported difficulty reaching the facility and said the communication book had not been filled out for a long time, while the DON confirmed the nurses were not completing the dialysis communication forms even though vital signs were available.
Dialysis Access Monitoring and Order Documentation Deficiencies: The facility failed to document daily access site assessments for a resident receiving HD, with records showing checks on dialysis days but not on non-dialysis days. The facility also lacked a complete physician order for another resident’s dialysis schedule, clinic location, and chair time, even though staff confirmed the resident went to dialysis on M/W/F and the care plan was not updated to match the current schedule.
The facility failed to have an active agreement with the dialysis center for two residents who were dependent on dialysis. One resident had diabetes, a leg amputation, and ESRD, and the other had diabetes and renal dialysis dependence. The Administrator stated the facility did not have a contract with the dialysis center and was waiting to receive one.
A resident with ESRD, DM, and malnutrition did not have dialysis communication forms completed with snack or food before transport, chair time, or post-dialysis assessment details. Meal intake, refusals, and substitutions were not consistently documented, and staff and family reported the resident often missed meals, did not receive alternatives, and had a hypoglycemic episode after insulin when he refused a meal tray.
A resident with ESRD and dependence on renal dialysis had orders and a care plan for dialysis three times weekly, but the facility could not retrieve dialysis communication forms and the binder was empty. An LPN said the forms were used to share pre- and post-dialysis vital signs and new orders, while the DON stated the dialysis center changed the resident’s schedule to two treatments per week without notifying the facility. A handwritten note and dialysis attendance record showed the resident was scheduled for two weekly treatments and often missed appointments.
Missed Dialysis Access Assessments: A resident receiving HD for ESRD with a LUE AV fistula did not consistently receive required fistula and post-dialysis assessments. The care plan and EMR directed staff to complete dialysis evaluations before dialysis, after dialysis, and on non-dialysis days, but records showed signed-off assessments with missing data on non-dialysis days and a missed post-treatment check on a dialysis day. The resident reported that staff often checked VS before dialysis but not afterward or on days without dialysis, and the DON acknowledged that post-dialysis checks did not always occur.
Incomplete Dialysis Communication Records
Penalty
Summary
The facility failed to ensure ongoing communication and collaboration with the dialysis provider for two residents who required dialysis services. One resident was admitted with hemiplegia affecting the left nondominant side and end stage renal disease, with an order for hemodialysis on Tuesday, Thursday, and Saturday. The resident’s hemodialysis communication records for multiple dates showed sections that were not completed and not signed by the nurse, including sections to be completed before transfer and upon return from dialysis. During interview, staff stated the facility communicated with dialysis nurses through a communication book, but the dialysis RN reported difficulty communicating with the facility and stated that the communication book had not been filled out for a long time. A second resident was admitted with multiple rib fractures and chronic kidney disease stage 3, with orders for dialysis on Monday, Wednesday, and Friday and for communication with the dialysis center regarding labs and plan of care. The resident’s dialysis communication records for two dates showed the section to be completed by the facility upon return from dialysis was not completed and not signed by the nurse. The facility policy stated that agreements with the contracted ESRD facility include how information will be exchanged between facilities, but the records and interviews showed that the required dialysis communication documentation was not consistently completed.
Dialysis Access Monitoring and Order Documentation Deficiencies
Penalty
Summary
The facility failed to ensure that a resident receiving hemodialysis had the dialysis access site assessed within the standards of practice. The resident had diagnoses of dependence on dialysis and diabetes mellitus, and the record showed intact cognition with a BIMS score of 15. The care plan directed staff to complete a dialysis flow sheet daily, observe the shunt access site for complications, report abnormalities to the physician, and avoid blood pressure checks and needle sticks in the right arm. Although dialysis communication sheets showed access site assessments on dialysis days, the resident’s EMR lacked evidence that staff monitored and assessed the access site on non-dialysis days. During observation on 06/03/26, the resident was seen in the dining room before leaving for dialysis. A licensed nurse stated that nursing staff obtained vital signs and weights pre- and post-dialysis and that the resident attended dialysis every day except Thursday, Saturday, and Sunday. The nurse also stated staff checked the access site on the days the resident went out for dialysis and could not find documentation of access site checks on Thursday, Saturday, and Sunday. An administrative nurse later stated the access site should be accessed and documented daily on the MAR or TAR. The facility also failed to ensure that another resident had an active physician’s order that included the dialysis clinic, location, chair time, and days of treatment. That resident had diagnoses of CKD stage 4 and type 2 diabetes mellitus, with records showing hemodialysis during the observation period and a BIMS score of 15 on one assessment and 7 on another. The care plan listed dialysis days and chair time, but it had not been updated to reflect the resident’s current Monday, Wednesday, and Friday schedule at 05:15 AM or the current transportation provider. The EMR contained orders for access monitoring, pressure dressing removal, and pre- and post-dialysis assessments, but it lacked a physician’s order specifying the dialysis clinic, clinic location, chair time, or days of dialysis. Staff interviews confirmed the resident went to dialysis on Monday, Wednesday, and Friday and that the physician’s order should include when, where, and what days dialysis occurred.
Missing Dialysis Center Contract for Two Residents
Penalty
Summary
The facility failed to have an active agreement and contract with the dialysis center for two residents who required dialysis services. Resident 103 was admitted with diagnoses including diabetes, leg amputation, and end stage renal disease, and was dependent on dialysis. Resident 2 was admitted with diagnoses including diabetes and was also dependent on renal dialysis. Both residents were able to communicate their needs. Review of facility contracts showed no active agreement with the dialysis center where these two residents were receiving dialysis, and the Administrator stated the facility did not have an agreement or contract with the dialysis center and was waiting to receive one.
Dialysis Nutrition and Communication Documentation Not Completed
Penalty
Summary
The facility failed to ensure safe, appropriate dialysis care and services for a resident with ESRD, dialysis dependence, moderate protein-calorie malnutrition, and type 2 DM with hyperglycemia. The resident’s care plan identified dialysis needs and also identified unplanned weight loss and risk for malnutrition, with interventions to monitor and record food intake at each meal and provide supplements as ordered. The resident’s active orders included Nepro three times daily for weight loss and decreased appetite, as well as a renal-liberalized diet with a high-protein snack between meals. Record review of the dialysis communication forms showed that on multiple dialysis days the resident was sent to dialysis without a snack or food. The forms also did not document the day and/or chair time for treatment on several dates, and they did not show completion of assessment and observation after dialysis on some dates. Progress notes from the same period did not document daily food intake for each meal, refusals, or substitutions. The record also did not show that the resident was sent to dialysis with a high-calorie snack or received a meal prior to dialysis when a scheduled time at the facility was missed. The resident and family reported that the resident often did not eat facility meals, that family brought food for him, and that staff did not offer another meal or snack when he did not like the food. The resident reported refusing meals because food was cold and said staff did not warm it or offer anything else. A progress note documented that the resident had a hypoglycemic episode after receiving scheduled insulin and then refusing the meal tray; the note also stated he did not eat a snack or lunch tray and received a meal replacement shake after the episode occurred. Staff interviews confirmed expectations that dialysis residents should receive food or a snack before dialysis and that meal refusals should be addressed with an alternative, but the DON stated the facility did not have a dialysis policy because it did not provide the treatment.
Missing Dialysis Communication and Unnotified Schedule Change
Penalty
Summary
The facility failed to maintain ongoing communication for a resident receiving dialysis services. Resident B had diagnoses including end stage renal disease and dependence on renal dialysis, was cognitively intact, and had a care plan and physician orders for dialysis three times per week on Monday, Wednesday, and Friday. The resident’s record contained no dialysis communication forms after 3/20/26, and the dialysis communication binder behind the nurse’s station was empty when reviewed. LPN 3 stated the dialysis communication forms were used to communicate pre- and post-dialysis vital signs and any new orders or instructions from the dialysis center. During interview, the Facility Administrator stated the binder had been emptied after the resident died and that the transportation service may have had the communication sheets. The DON stated the dialysis center changed the resident’s dialysis order from three days per week to two days per week without notifying the facility. A handwritten note with dialysis appointment dates indicated the resident had been scheduled two days per week and often missed dialysis appointments. The facility later provided a dialysis contract stating the center would maintain reports of services rendered and the facility could photocopy those reports, along with a treatment attendance record showing dialysis treatments were prescribed two times per week on Monday and Friday.
Missed Dialysis Access Assessments
Penalty
Summary
The facility failed to ensure post-dialysis assessments and fistula assessments were consistently completed for a resident who received hemodialysis for end stage renal disease and had an AV fistula in the left upper extremity. The resident’s care plan directed staff to listen to and feel the dialysis site before dialysis, after dialysis, and on non-dialysis days, and the electronic record also directed completion of a dialysis evaluation before dialysis, after dialysis, and on non-dialysis days. The resident had intact cognition and reported that nurses often checked vital signs before dialysis but frequently did not check her afterward or on days without dialysis, and she stated that no one had checked her access site the previous day. Record review showed that on two non-dialysis days, staff signed off that the dialysis assessment was completed even though the actual evaluation data was missing. On a dialysis day, the facility failed to perform the required check after the resident returned from treatment. Staff confirmed that dialysis residents were expected to be evaluated every day, including assessment of the fistula for thrill and bruit and vital signs before and after dialysis appointments. The DON acknowledged that post-dialysis checks did not always happen and stated that daily checks on non-dialysis days only occurred if specifically ordered, with missed checks to be documented as refused or if the resident was out of the building.
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