Failure to Maintain Required Emergency Dialysis Catheter Clamps at Bedside
Penalty
Summary
The deficiency involves the facility’s failure to provide dialysis-related care consistent with professional standards and the resident’s care plan for a resident with end stage renal disease, anemia in chronic kidney disease, and dependence on renal dialysis. The resident had a central venous catheter in place and a care plan focus identifying risk for worsening impaired renal function and complications related to hemodialysis, initiated on 10/7/25. The care plan included an intervention, also initiated on 10/7/25, to maintain smooth catheter clamps at the bedside and on the resident when out of bed in case of catheter breakage or excessive bleeding. During an observation on 12/8/25 at 1:00 PM, surveyors noted that no smooth clamps were located at the bedside in the resident’s room. In a subsequent interview on 12/9/25 at 2:30 PM, the Unit Manager stated the resident should have an emergency kit at the bedside that includes smooth clamps and directed a nurse to check the kit; the nurse reported that while the kit was present, it did not contain the clamps. A further observation on 12/9/25 at 3:16 PM with the DON and Unit Manager confirmed that the emergency kit in the resident’s room did not include the required smooth clamps, and the DON acknowledged that the clamps needed to be added and that the emergency kit should be with the resident at all times, including when off-site for dialysis.
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