F0610

D

Failure to Investigate Resident Death Following Dialysis and Missing Interfacility Documentation

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

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to investigate an alleged incident related to a resident’s death following a dialysis treatment, despite policies requiring thorough investigation of all occurrences not consistent with routine operations and care. Facility policy on Reporting and Investigating Resident Accident/Incidents required that all such occurrences, including those that may have caused physical injury or harm, be reported, reviewed, and thoroughly investigated, with completion of an Accident/Incident Report, review of the care plan and CNA profile, and appropriate notifications. The policy also referenced federal regulation 42 CFR 483.13 regarding injuries of unknown source and outlined that incidents with injury without known incident and where abuse or care plan violation could not be ruled out must be reported to the New York State Department of Health and to the Director of Investigations and Administrator. Despite these requirements, there was no documented evidence that the facility conducted any investigation into the circumstances surrounding the resident’s condition upon return from dialysis and subsequent death.

The resident involved had chronic kidney disease on dialysis, cellulitis of the right lower leg, and malignant neoplasm of the endometrium, and was minimally cognitively impaired but able to understand and be understood. On the day in question, the resident left the facility around 11:00 AM for hemodialysis and was observed on video at noon leaving the facility in a wheelchair, upright, with an oxygen tank, and communicating with staff and the transport driver. A facility policy on Renal Dialysis required that residents be sent with a communication book containing an Interfacility Report completed prior to transport, and that the dialysis unit complete its section and a Dialysis Information Sheet before the resident’s return. However, the Dialysis Communication Sheet for that day, and for the prior dialysis visit, showed that the dialysis center’s section was left blank.

Later that day, video showed the resident returning around 6:00 PM slumped to the left in the wheelchair, wrapped in a blanket, wearing a mask with oxygen tubing visible, and not interacting with the transport driver or the friend who met them. The friend’s written statement 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. The friend further documented that when they returned to pick the resident up, the resident appeared unconscious, was not moving, and did not respond, and that dialysis staff reported the resident had been crying and yelling and then fell asleep during treatment. Upon arrival back at the facility, the friend noted the resident was limp and drooling and brought them to the nursing station, where staff quickly attended to the resident.

Multiple staff interviews confirmed that upon return from dialysis, the resident was unresponsive, with staff unable to obtain vital signs and a nurse confirming the resident was pulseless with blue lips and mottling of the hands and fingers. The resident was pronounced deceased shortly after arrival. Staff, including the ADON and an RN, attempted to call the dialysis center but were unable to reach anyone, and there was no other resident using that dialysis facility for comparison. The DON and Administrator both acknowledged that no facility investigation was conducted into what happened to the resident at dialysis or during transport, and there was no documentation of what items were sent with the resident or any checklist used. The DON stated that because the resident arrived with no pulse or respirations and had a Do Not Resuscitate order, there was nothing to investigate, and the Administrator stated that no investigation was done because it was believed the resident had died at dialysis. This lack of investigation into an unusual occurrence involving a resident’s death, in the context of missing dialysis documentation and unanswered calls to the dialysis center, constituted the cited deficiency under 10 NYCRR 415.4(b)(3).