F0609

D

Failure to Report Unexplained Death Following Dialysis to State Authorities

East Greenbush, New York Survey Completed on 03-19-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to report an alleged incident related to possible abuse, neglect, exploitation, or mistreatment to the New York State Department of Health as required, following the death of a resident who had been transported to and from dialysis. Facility policy required that all occurrences not consistent with routine operations and resident care that had or may have caused physical injury or harm be reported, reviewed, and thoroughly investigated, including completion of an Accident/Incident Report and, when applicable, abuse investigation materials. The policy also specified that injuries of unknown origin and incidents where the facility could not rule out abuse or a care plan violation must be reported to the Department of Health and that the Director of Investigations and Administrator be notified as soon as possible. Despite these requirements, there was no documented evidence that the events surrounding this resident’s death were reported to the state.

The resident had chronic kidney disease on dialysis, cellulitis of the right lower leg, and malignant neoplasm of the endometrium, and was assessed as minimally cognitively impaired and able to understand and be understood. On the day of the incident, the resident left the facility around late morning for hemodialysis and returned in the early evening. Video footage showed the resident leaving the facility in a wheelchair, upright, with an oxygen tank, and communicating with staff and the transport driver. A second video showed the resident returning from dialysis slumped to the left, wrapped in a blanket, wearing a mask with oxygen tubing visible, and not interacting with the driver or the friend who was waiting. The friend later documented that the resident arrived at the dialysis center uncomfortable, crying, and disoriented but still able to state their name, address, and recognize the friend, and that upon pickup after treatment the resident appeared unconscious, was not moving, and did not respond.

Upon arrival back at the facility, the friend reported that the resident was limp and drooling and brought them to the nursing station, where staff quickly attended. Nursing staff attempted to obtain vital signs and a fingerstick; the fingerstick was believed to be within normal limits, but the blood pressure machine was not reading, and staff could not recall if an oxygen saturation reading was obtained. Multiple nurses observed that the resident was unresponsive, pulseless, with blue lips and mottling of the hands and fingers, and the resident was pronounced deceased shortly after return. The dialysis communication sheet showed that facility staff had documented pre-dialysis vital signs, but the section to be completed by the dialysis center was blank for this and the prior treatment, and attempts by the ADON and other staff to reach the dialysis center by phone were unsuccessful. The DON acknowledged there was no facility investigation into what happened at dialysis, stated that because the resident arrived with no pulse or respirations and had a DNR there was nothing to investigate, and reported that it did not occur to them that the incident should have been reported to the Department of Health. The Administrator similarly stated that no investigation was done because it was believed the resident had died at dialysis, and only in hindsight acknowledged they should have looked into it further. There was no documentation of a report to the state despite the unexplained circumstances and lack of information from the dialysis provider.

The facility’s own policies on reporting and investigating incidents and on renal dialysis required thorough documentation, communication with the dialysis center, and reporting of incidents where the facility could not rule out abuse or a care plan violation. Staff interviews revealed that CNAs did not document in the dialysis communication book, that the dialysis center had not been completing its portion of the communication sheets for this resident’s treatments, and that there was no checklist or documentation of what items were sent with the resident to dialysis. The Director of Transportation confirmed that transport drivers were not medically trained and might not recognize subtle changes in condition. Despite these gaps and the unexplained change in the resident’s condition between departure and return, the facility did not initiate an internal investigation or report the incident to the New York State Department of Health as required by policy and regulation.