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 Documentation: The facility failed to fully complete the dialysis communication sheet for a resident receiving dialysis services. An LPN stated staff completed assessments and communication sheets before dialysis and upon return, while the DON said staff were expected to complete the sheets completely. Review showed multiple return-from-dialysis sections were left blank, and no earlier communication sheets were provided.
Failure to Document Post-Dialysis Assessment: A resident with ESRD who received hemodialysis twice weekly returned from treatment and reported staff rarely assessed her afterward or checked her chest port. The RN confirmed a pre- and post-dialysis assessment should have been completed and documented on the Dialysis Communication Form, but no post-dialysis assessment was found in the EMR and there was no evidence the resident refused care.
Incomplete Post-Dialysis Assessment Documentation: A resident with DM, COPD, and dependence on dialysis had repeated missing post-HD assessments on the dialysis communication sheet. The care plan and MD orders included dialysis attendance, AV fistula/graft monitoring, and pre-dialysis weights, but staff stated the resident was to be assessed after returning from dialysis and documented on the communication sheet; however, post-dialysis documentation was absent on many dialysis dates.
A resident with ESRD, DM2, and dependence on dialysis missed a scheduled hemodialysis treatment because transport was not arranged after a hospital return. The resident was observed waiting in the lobby for pickup, and staff later stated the dialysis center had not been updated about the hospitalization. The SSD and RT both acknowledged the facility was responsible for notifying the dialysis center and arranging transport, and the dialysis agreement and dialysis monitoring policy reflected that responsibility.
Failure to Monitor Fluid Restriction for a Resident Receiving Dialysis: A resident with ESRD, dependence on renal dialysis, and pleural effusion had a physician-ordered 1200 ml/day fluid restriction, but the MAR and record review showed no documentation of oral intake monitoring. The RNS stated she could not find intake monitoring documentation and noted the resident also lacked a care plan for the fluid restriction, despite facility P&P requiring intake/output documentation and a plan of care for residents on fluid restrictions.
A resident receiving PD was involved in a procedure where an RN did not perform hand hygiene before donning gloves, entered the room without closing the door, and then put on a mask from the resident’s bedside table while continuing the same procedure. The facility’s PD disconnecting procedure required the door to be closed, a mask to be applied, and hand hygiene to be performed before gloves were applied, and the RN had not received facility training related to the resident’s PD.
Incomplete Dialysis Communication Documentation
Penalty
Summary
The facility failed to complete the dialysis communication sheet for one resident who required dialysis services. The resident had a physician order dated 5/20/2026 for dialysis at a third-party dialysis provider on Tuesday, Thursday, and Saturday, with a 7:00 AM pickup time and 7:30 AM chair time, transported by wheelchair. Review of the resident’s dialysis communication forms showed that the section for facility completion upon return from dialysis was not completed on 8/8/2026, 8/6/2026, 8/4/2026, 8/1/2026, and 7/28/2026, and no other communication sheets were provided prior to 7/28/2026. Staff interviews indicated that an LPN completed assessments and communication sheets before dialysis and upon return, and the DON stated that staff were expected to complete the communication sheets completely and that progress notes would be on the communication sheet. The facility policy titled Clinical Dialysis Management stated that facility personnel will provide information useful or necessary for the resident’s care to the dialysis center as needed.
Failure to Document Post-Dialysis Assessment
Penalty
Summary
The facility failed to complete and document a post-hemodialysis assessment for a resident with end-stage renal disease who received dialysis twice weekly and had intact cognition with no refusal of care documented. The resident’s care plan noted that she returned from dialysis tired, often went straight to her room to nap, and required monitoring for increased fatigue and assistance with activities of daily living and mobility as needed. Her EMR also included orders related to her chest port dressing, including routine dressing changes and sterile care instructions. On the day in question, the resident returned from dialysis and stated that staff rarely assessed her when she came back from treatment and did not check her port. She exposed the chest port during the interview, and the dressing was dry and intact without bleeding or drainage. Review of the resident’s progress notes, evaluation notes, and EMR found no documentation of a post-dialysis assessment, and there was no evidence that she refused the assessment. The nurse on duty confirmed that a pre- and post-dialysis assessment should have been completed and documented on the Dialysis Communication Form, but she could not locate the form for that day and stated she did not recall seeing it when the resident returned.
Incomplete Post-Dialysis Assessment Documentation
Penalty
Summary
Safe, appropriate dialysis care/services were not provided for a resident who required hemodialysis. The resident had diagnoses of DM, COPD, dependence on dialysis, and dependence on supplemental oxygen, and the MDS documented a BIMS score of 15 with dialysis received during the observation period. The care plan included interventions for dialysis attendance, shunt monitoring, blood pressure precautions for the shunt arm, and daily weights, but the dialysis-related documentation was incomplete. The physician orders included dialysis on Monday, Wednesday, and Friday, readiness for dialysis by 10:30 AM, monitoring of the AV fistula/graft site upon return from dialysis, and weighing before dialysis for fluid management. Review of the Dialysis Communication Form from 05/01/2026 through 08/03/2026 revealed 41 dialysis communication sheets, and post-dialysis documentation was missing on 25 dates. The facility’s staff stated the resident would be assessed upon return from dialysis and documented on the dialysis communication sheet, and administrative staff stated the charge nurse was expected to complete and document the post-return assessment. The facility’s Hemodialysis policy stated it would provide care and treatment consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the resident’s goals and preferences.
Missed Dialysis Transport for Resident Requiring Hemodialysis
Penalty
Summary
The facility failed to ensure a resident who required hemodialysis was transported to treatment. Resident #106 was admitted with diagnoses including dependence on renal dialysis, end stage renal disease, type 2 diabetes mellitus with diabetic neuropathy, and hypertensive heart and chronic kidney disease with heart failure and end stage renal disease. The care plan identified that he was dependent on dialysis and received hemodialysis three times a week. He had a BIMS score of 13, indicating no cognitive impairment, and was dependent on staff for activities of daily living with impaired upper and lower extremities bilaterally. After the resident returned from the hospital, physician orders continued hemodialysis three times weekly with a 6:15 A.M. pickup time and instruction to be in the lobby at 5:15 A.M. On the morning of the missed treatment, the resident was observed waiting in his wheelchair in the lobby and later stated he was waiting for dialysis transport. Staff later told him he had missed the appointment because transportation had not been set up. The SSD stated it was the facility's responsibility to call and alert the dialysis center of updates, including hospitalizations. The RT stated the dialysis transport was automatic, but when the resident transferred to the hospital the facility did not update the dialysis center, and the center stopped coming after unsuccessful pickup attempts. The facility's dialysis transfer agreement stated it was responsible for arranging transportation to and from the dialysis center, and the dialysis monitoring policy stated the facility would maintain the safety and health of residents receiving dialysis services.
Failure to Monitor Fluid Restriction for a Resident Receiving Dialysis
Penalty
Summary
The facility failed to monitor the fluid restriction for Resident 10, who was admitted and readmitted to the facility with diagnoses including ESRD, dependence on renal dialysis, and pleural effusion. The resident’s MDS dated 6/26/2026 indicated moderate cognitive impairment and dependence for multiple activities of daily living, with setup or clean-up assistance needed for eating and oral hygiene. A physician order dated 7/10/2026 specified a fluid restriction of 1200 ml per day, but during review of the MAR on 7/23/2026, there was no documentation of the resident’s oral intake to show that the restriction was being monitored. The RNS stated she could not find any documentation of oral intake monitoring and also stated the resident did not have a care plan reflecting the 1200 ml fluid restriction. The facility’s P&P for Fluid Restriction required intake and output documentation and a plan of care for residents on fluid restrictions, and the Dialysis Management P&P stated that diet and fluid restrictions would be followed as ordered and documented in the medical record.
Failure to Follow PD Disconnect Procedure
Penalty
Summary
The facility failed to implement care consistent with professional standards of practice to prevent potential complications from a dialysis access site for one resident receiving peritoneal dialysis. The facility’s procedure for disconnecting PD directed staff to close the resident’s door, apply a mask, and then wash hands and apply gloves before accessing the PD port. During observation of the resident’s PD disconnecting procedure, a registered nurse placed gloves on without performing hand hygiene, entered the resident’s room without closing the door, and then applied a mask from the resident’s bedside table while continuing the procedure with the same gloves. The record also showed that the nurse had not received any facility training related to the resident’s PD.
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