F0561

D

Failure to Honor Resident’s Post-Dialysis Preference to Return to Bed

Charlotte, North Carolina Survey Completed on 03-02-2026

Penalty

Fine: $26,685

Summary

The deficiency involves the facility’s failure to honor a cognitively intact resident’s clearly expressed preference to return to bed immediately after dialysis, despite staff awareness of this routine. The resident had chronic kidney disease stage 4 requiring hemodialysis three times weekly and type 2 diabetes mellitus, and was dependent on staff for transfers via mechanical lift. Her MDS indicated it was very important for her to choose her bedtime, and she had a dialysis care plan noting scheduled treatments on specific days. The resident reported that her dialysis days began at 2:00 AM and that she was extremely tired and ready to return to bed upon arrival back at the facility, yet she sometimes waited until after lunch to be placed back in bed.

On an observed dialysis return day, the resident arrived back on the unit around 10:40 AM and activated her call light at 10:43 AM. An agency nurse aide (NA #10) entered the room at 10:45 AM, turned off the call light, and told the resident she was completing rounds and would return, but did not allow the resident to state her needs and did not request assistance from other staff. The call light remained off and the resident was not assisted back to bed at that time. The resident later reactivated her call light at 11:25 AM. Another nurse aide (NA #7) responded at 11:28 AM, turned off the call light, and informed the resident she needed another staff member to assist with the mechanical lift transfer, as two staff were normally required for such transfers.

NA #7 attempted to assist the resident at 11:34 AM but had to leave to obtain help, stating she had requested assistance from another staff member. The resident reactivated her call light again at 11:40 AM. At 11:43 AM, the certified occupational therapy assistant (COTA #1) and NA #7 returned and transferred the resident back to bed with the mechanical lift without concerns. During this period, the resident reported feeling very tired and lightheaded from dialysis and stated she had been waiting over 45 minutes. Interviews with regular staff and the unit manager confirmed that staff were generally aware that the resident preferred to go to bed as soon as possible after dialysis, and that usual practice was to assist her within about 10–15 minutes. NA #10, however, as agency staff, reported not receiving a full report, was unaware of the resident’s preference, did not communicate the need to other staff, and did not return to the resident after assisting another resident, resulting in an extended delay in honoring the resident’s request to return to bed after dialysis.

Additional interviews further clarified the sequence of inactions that led to the deficiency. NA #10 acknowledged that she was assigned to the resident that day for bathing and dressing, that the resident had voiced she was ready to lie down after dialysis, and that she did not notify or request assistance from other staff members despite being occupied with another resident on a different hall. She also stated she believed it was not the responsibility of other staff to address needs for residents on her assignment and that she had not received report regarding the resident’s post-dialysis preference. NA #7 and COTA #1 both confirmed that staff were aware the resident liked to go to bed upon return from dialysis and that the delay on the observed day was atypical. Facility leadership, including the unit manager, DON, and administrator, confirmed that staff were expected to respond promptly to call lights and that the resident, being alert and oriented, could clearly communicate her preferences and choices, including the request to return to bed after dialysis, which was not honored in a timely manner on the observed occasion.