F0698

E

Missed Hemodialysis Treatments and Lack of Monitoring for ESRD Resident

Long Beach, California Survey Completed on 03-09-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that a resident with ESRD received ordered hemodialysis (HD) treatments and that her dialysis-related care plan was implemented. The resident was admitted with diagnoses including joint replacement surgery and ESRD requiring HD, with physician orders for HD on Monday, Wednesday, and Friday at a specified time, and transportation arranged for pickup prior to each treatment. Her care plan, initiated shortly after admission, identified a need for dialysis with goals of avoiding complications related to fluid overload and maintaining normal weight, and included interventions to provide HD on the ordered schedule and to monitor for changes in level of consciousness, vital signs, heart and lung sounds, and edema, with reporting to the primary physician as needed.

Record review showed no documentation that the resident received HD on two ordered treatment days and no documentation that licensed nurses identified, monitored, or assessed her for complications related to the missed HD treatments on those days. The resident’s emergency contact reported that the resident missed an HD treatment because transportation did not pick her up, and that an additional treatment scheduled for the following day was also missed due to the same transportation issue. The emergency contact expressed concern that the resident would retain excess fluids because her kidneys were no longer functioning.

Multiple staff interviews confirmed breakdowns in both transportation coordination and nursing follow-through. The RN Supervisor acknowledged that on the morning shift when the resident reported missing HD due to lack of transportation, she did not assess or monitor the resident for a change in condition, did not notify the primary physician, and did not initiate monitoring for potential complications. The Case Manager stated she had confirmed transportation and arranged an extra HD treatment, documented it on the communication board, and informed the RN Supervisor, while another RN reported endorsing the extra HD appointment to the next shift. However, the RN working the following morning shift stated she did not receive endorsement or see any communication board note about the appointment. Staff also confirmed that despite the resident missing two HD appointments, there was no monitoring initiated, no specific plan of care formulated for the missed HD, and no notification of the primary physician. When the resident presented to the dialysis center at the next scheduled treatment, the dialysis clinical coordinator assessed her with facial and generalized body edema and documented that she was 11 kg above her prescribed target weight.

Policy review showed that the facility’s transportation policy required assistance with arranging transportation as needed, the ESRD policy required that residents with ESRD be cared for according to recognized standards and that licensed nursing staff be trained to recognize signs and symptoms of worsening condition or complications, and the change-in-condition policy required prompt physician notification and detailed documentation, including at least 72 hours of monitoring, vital signs each shift, evident care plan, and reassessment when a change in condition occurred. These policy requirements were not followed in relation to the missed HD treatments and lack of monitoring and assessment for this resident.