Failure to Assess and Monitor Dialysis Resident Post-Treatment Resulting in Fatal Hemorrhage
Summary
A deficiency occurred when a resident with end-stage renal disease, anemia, atrial fibrillation, and a history of removing her own dialysis access site dressing was not properly assessed or monitored upon return from an outpatient hemodialysis treatment. The resident was prescribed Eliquis, increasing her risk for bleeding, and had documented prior incidents of prematurely removing her AV fistula dressing, resulting in bleeding. Despite these known risks and care plan interventions requiring monitoring of the access site and leaving the dressing in place for at least four hours post-dialysis, staff failed to conduct a post-dialysis assessment or monitor the resident for complications upon her return. On the day of the incident, the resident returned to the facility at approximately 7:10 p.m. after hemodialysis. The assigned RN assisted the resident to her room but did not visually inspect the AV fistula site, check vital signs, or document the resident's return. The RN assumed the site was not bleeding because the resident's clothing was not wet and did not notify other staff of the resident's return. Both the LVN and CNA assigned to the resident were on their lunch breaks and were not informed of the resident's return. No staff member was designated to receive or assess the resident upon her arrival, and there was no documentation of a post-dialysis assessment in the medical record. Approximately 40 minutes later, the CNA discovered the resident unresponsive, with the AV fistula dressing removed and active bleeding from the site. Blood was found on the bed, floor, and the resident's clothing. Emergency measures were initiated, but the resident was pronounced deceased by paramedics. Interviews and record reviews confirmed that facility staff did not follow established policies and procedures for post-dialysis assessment, monitoring, and documentation, nor did they implement the resident's care plan interventions for AV fistula care and monitoring.
Removal Plan
- The DON conducted a comprehensive review of Resident 1's hemodialysis-related care upon Resident 1's return from the hemodialysis treatment, including interviews with RN 1 and LVN 1, review of facility's P&P on Dialysis Care, forms used for dialysis care, nurses progress notes, and communication related to Resident 1's return from dialysis treatment, identifying failures related to post-dialysis assessment, monitoring, communication, and documentation.
- All residents returning from hemodialysis treatment or any off-site procedure will be assessed upon return at the soonest practicable time by the Charge Nurse and/or RN, including direct inspection of the hemodialysis access site, vital signs, bleeding assessment, condition of the resident, documentation of findings in the nursing progress notes, and the Nursing Facility Post Dialysis Assessment form. CNA will immediately notify any licensed nurse of any observed signs of bleeding or distress and will endorse findings to the LVN Charge Nurse and/or RN.
- The DON and Medical Records staff conducted an audit on the Nursing Facility Pre and Post Dialysis Assessment forms for eight residents receiving hemodialysis treatment, finding no other residents with deficiencies similar to those found for Resident 1.
- The Administrator and the DON reviewed and updated the P&P on Dialysis Care. The Dialysis Flow Sheet-Return Assessment form was updated to include signature columns for the Charge Nurse and RN Supervisor, as well as the inclusion of the Nursing Facility Pre and Post Dialysis Assessment form. The updated policy became effective and will be presented to the Quality Assurance Committee at the next monthly meeting.
- The Administrator notified the Medical Director regarding the details of the IJ issued by the SSA and the updated policy on Dialysis Care.
- The DON provided one-on-one in-service to RN 1 and LVN 1, who were assigned to Resident 1 during the 3 p.m. to 11 p.m. shift regarding P&P on Dialysis Care, focusing on conducting pre and post dialysis assessments, assessing the dialysis access site for signs of bleeding, resident's medical condition and other complications, and documentation requirements.
- The facility will ensure that residents who require hemodialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.
- The DON and DSD provided in-service education to nursing staff regarding the updated policy on Dialysis Care, with emphasis on comprehensive assessment and monitoring of residents by LVNs or RNs post dialysis treatment, completion of the Nursing Facility Post-Dialysis Assessment form, the Dialysis Flow Sheet-Return Assessment, and nursing progress notes documenting the date and time residents return to the facility.
- The DON performed a competency check of RN 1 regarding dialysis care, including monitoring, documentation, and communication.
- The DON performed competency checks of licensed nurses regarding post dialysis observation, reporting, monitoring, interventions, and proper documentation.
- The DSD performed competency checks of CNAs regarding observation and reporting on resident's return post-dialysis and post procedure, monitoring, safety, and communication of observations.
- The DON conducted an audit on residents who returned from hemodialysis, showing all requirements were completed and in place for each of the reviewed residents, and that a process is in place to ensure appropriate assessment, monitoring, documentation, and clinical oversight for residents returning to the facility following outpatient hemodialysis.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with ESRD, peripheral vascular disease, and an AV fistula returned from dialysis with a gauze dressing applied by the dialysis nurse, which remained in place into the following day. A physician order and care plan required nursing staff to remove the AV fistula dressing on the night of dialysis and assess the site for complications and signs of infection. The assigned nurse acknowledged she knew she was required to remove the dressing and assess the site but forgot because she was busy with another resident. The physician emphasized the importance of post-dialysis AV fistula assessment due to the resident’s vascular disease and prior complications, and the DON stated she expected staff to follow the order and routinely assess the fistula site.
A resident with an AVF in the right arm for hemodialysis had a physician order and care plan directing staff to keep the post-hemodialysis compression bandage on no longer than a specified number of hours and to assess and remove the dressing as ordered after each HD session. Documentation showed the resident returned from HD with the AVF dressing intact, clean, and dry and without bleeding or pain, yet the next morning the resident reported that staff had not removed the dressing, and observation confirmed the dressing was still in place. The DON and IDON verified the time-limited AVF dressing order and could not explain why the dressing had not been removed as required.
A resident with ESRD, COPD, severe cognitive impairment, and dependence on hemodialysis had physician orders for dialysis three times weekly with a set transportation pick-up and return time. On one treatment day, the resident was not picked up at the scheduled time, and progress notes showed the resident received only a partial dialysis session. The contracted transportation company reported that no transport had been scheduled initially and that they were called later in the morning, leading to a delayed pick-up. The SSD, who managed transportation based on standing dialysis orders, stated she did not track the contracted number of pick-up days or remaining trips, which resulted in the missed scheduled transport and shortened dialysis treatment, contrary to facility policies on transporting residents and providing appropriate hemodialysis care.
A resident with ESRD on dialysis, along with multiple comorbidities including CHF, COPD, A-fib, and Type 2 DM, had physician orders and a care plan for a therapeutic renal diet, a 1200 ml/day fluid restriction divided across meals and med passes, and no water pitcher in the room, consistent with facility policy for dialysis residents. Observations showed a full water pitcher at the bedside and meal trays providing more than the ordered 240 ml of fluid per meal, while documentation also reflected conflicting fluid restriction amounts. Staff confirmed the resident had been offered more fluid than ordered and that a water pitcher had been present. In addition, on a dialysis day, multiple scheduled 9 a.m. medications were not administered because the resident was away at dialysis and the facility had not coordinated medication timing around dialysis services, contrary to its own policy.
A resident with ESRD on hemodialysis, diabetes, and paraplegia was not consistently transported to dialysis on time and did not receive fully documented pre- and post-dialysis assessments as ordered. The resident reported being late to dialysis once or twice weekly, arriving after the expected chair time, and dialysis staff confirmed at least one missed transport due to the resident not being ready. Review of the MAR showed repeated omissions in required assessments of thrill, bruit, access site condition, cognition, and weight on multiple dialysis days, with no explanations in the record. Facility leadership and nursing staff described expectations for timely readiness for transport and comprehensive post-dialysis assessments, but the documentation and resident reports demonstrated that these expectations were not met.
A resident with heart failure, CKD, and cirrhosis who received hemodialysis three times weekly missed one or more scheduled dialysis sessions when a malfunctioning elevator prevented timely transport, with staff and the resident confirming that elevator breakdowns had caused missed appointments and led to the resident’s relocation to a lower floor. Review of the hemodialysis communication book over several weeks showed that on most documented dialysis days, either the pre- or post-dialysis nursing assessment was missing, and there was no corresponding documentation in the EMR, despite facility policy requiring complete pre- and post-treatment assessments for dialysis care.
Failure to Remove Dialysis AV Fistula Dressing and Perform Ordered Assessment
Penalty
Summary
The facility failed to follow a physician’s order to remove a dressing and visually assess a resident’s arteriovenous (AV) fistula after dialysis. The resident, who had diagnoses including AV fistula, end stage renal disease, dialysis, and peripheral vascular disease, was cognitively intact and received dialysis. A physician order dated 2/2/2026 directed staff to remove the dressing to the AV fistula on the night of dialysis every Monday, Wednesday, and Friday to avoid skin breakdown and damage to the AV fistula. The resident’s care plan, updated on 2/27/2026, included interventions to check and change the AV fistula dressing as ordered and to observe the site for signs and symptoms of infection. On observation, the resident was noted to have a gauze dressing with tape on the left upper arm AV fistula the day after dialysis, and the resident reported that the dressing had been applied by the dialysis nurse after treatment. The nurse assigned to the resident on the 3:00 PM to 11:00 PM shift acknowledged that she was supposed to remove the dressing and assess the AV fistula site when the resident returned from dialysis but stated she forgot because she was busy with another resident. The physician stated that it was important for nursing staff to remove the dressing and assess the AV fistula after dialysis due to the resident’s significant vascular disease and history of complications with hypotension and falls after dialysis, and described the AV fistula as the resident’s lifeline. The DON stated that nursing staff usually removed the dressing and assessed the AV fistula site after dialysis and that she expected staff to follow physician orders and assess for signs and symptoms of infection.
Failure to Follow Post-Hemodialysis AVF Dressing Orders
Penalty
Summary
The facility failed to provide dialysis access site care as ordered for a resident receiving hemodialysis. The resident, who has an arteriovenous fistula (AVF) in the right arm for hemodialysis, reported that nurses at the facility typically remove the dressing on the day he returns from dialysis or the next morning. The resident’s electronic health record contained a physician order stating that upon return from dialysis, the compression bandage should be kept on no longer than four hours, and if there is known post-dialysis bleeding, the top compression bandage should be removed and the bottom bandage left in place for an additional two to three hours on every day and evening shift after dialysis. The resident’s care plan also directed staff to check and assess the dressing at the access site when back from dialysis and to remove the dressing on the AV fistula as ordered. Record review showed that an RN documented the resident’s return from hemodialysis in the early evening, noting that the AVF dressing was intact, clean, and dry, with no active bleeding and no pain reported at the site. The following morning, the resident was observed sitting in the hallway and confirmed that he still had a dressing on his access site and that he had undergone dialysis the previous day. Upon inspection, a dressing was observed on the upper right arm covering the AVF, indicating that the compression bandage had not been removed within the time frame specified by the physician’s order and care plan. The DON and interim DON confirmed the existence of the time-limited post-hemodialysis AVF dressing order and were unable to explain why the dressing remained in place the next morning.
Failure to Arrange Timely Transportation Resulting in Incomplete Dialysis Treatment
Penalty
Summary
The facility failed to ensure timely transportation for a resident with ESRD who required hemodialysis three times weekly, resulting in the resident arriving late and receiving only a partial dialysis treatment. The resident had diagnoses including COPD, ESRD, and dependence on renal dialysis, and had fluctuating capacity to understand and make decisions, with an MDS indicating severely impaired cognitive skills and a need for substantial/maximal assistance with activities of daily living. Physician orders specified dialysis on Tuesdays, Thursdays, and Saturdays with a scheduled transportation pick-up time of 7:15 a.m. and return at 12 p.m., and nursing staff confirmed there had been no changes to these transportation orders. On the date of the incident, progress notes documented that the resident was not picked up at the scheduled standing pick-up time for dialysis and subsequently received an incomplete dialysis cycle of only two and a half hours. The contracted transportation company reported that no transportation had initially been scheduled for that day and that they only received a call from the facility later that morning, resulting in a delayed pick-up at 10 a.m. The transportation company also stated that the resident’s transportation services had been reactivated to start on a later date. The Social Services Director, who was responsible for managing residents’ transportation based on standing dialysis orders provided by licensed nurses, acknowledged that she did not track the contracted number of pick-up days or remaining trips, which led to the resident not being transported on time and receiving only partial dialysis treatment. Facility policies stated that transportation to appointments would be facilitated by Nursing or Social Services and that the facility would provide safe, accurate, appropriate hemodialysis-related care and coordination.
Failure to Adhere to Dialysis Resident Fluid Restriction and Medication Scheduling
Penalty
Summary
Surveyors identified that the facility failed to follow its own policy for dialysis residents and to adhere to physician-ordered fluid restrictions and medication timing for one dialysis-dependent resident. The facility’s policy required that dialysis residents receive fluids only as ordered by the physician, that nursing and dietary staff organize the division and distribution of fluids, that no water pitcher be present when restricted, and that medications be administered before departure and after return from dialysis so as not to interfere with treatment. The resident had end stage renal disease on dialysis, Type 2 diabetes mellitus, atrial fibrillation, COPD, and chronic heart failure, with a care plan and orders specifying a therapeutic diet, low potassium, no added salt, double protein, and a 1200 ml/day fluid restriction divided as 240 ml at each meal and 120 ml with each med pass, and no water pitcher in the room. Despite these orders and care plan interventions, observations showed a 600 ml water pitcher in the room filled to the 500 ml mark, and lunch trays that included a 240 ml milk carton plus additional juice and ice, exceeding the ordered 240 ml fluid allotment at meals. Record review further showed conflicting fluid restriction documentation, with an After Visit Summary listing a 1500 ml fluid restriction while the facility’s orders and care plan reflected a 1200 ml restriction, and staff interviews confirmed that the resident had been offered more than the ordered 240 ml of fluid with meals and that a water pitcher had been present contrary to the care plan. Additionally, the facility failed to coordinate medication administration around dialysis treatments. The Medication Administration Record documented that multiple scheduled 9 a.m. medications, including atorvastatin, fluticasone nasal spray, linagliptin, sennosides-docusate, metoprolol tartrate, mucinex ER, carboxymethylcellulose eye drops, and ipratropium-albuterol inhalation solution, were not given on a dialysis day because the resident was away from the facility without medications. The DON confirmed that these medications were omitted due to the resident being at dialysis and acknowledged not knowing that medication administration should be scheduled around dialysis services, contrary to the facility’s dialysis care policy.
Failure to Ensure Timely Dialysis and Complete Pre/Post-Dialysis Assessments
Penalty
Summary
The facility failed to ensure that a resident who required hemodialysis consistently attended dialysis on time and received thorough pre- and post-dialysis assessments as ordered. The resident had renal insufficiency requiring dialysis, diabetes mellitus, paraplegia, and intact cognition, and was scheduled for dialysis on Monday, Wednesday, and Friday with a pick-up time of 9:30 AM. Review of the clinical record and MAR showed that required pre- and post-dialysis assessments were not fully completed on multiple dates, including missing documentation for thrill, bruit, access site condition, cognition, and weight, with no explanations in the record for these omissions. The facility’s hemodialysis policy required ongoing assessment and monitoring for complications before and after treatments, but the documentation did not reflect that these assessments were consistently performed. The resident reported being late to dialysis once or twice a week, stating she was supposed to be in the dialysis chair by 10:00 AM but often did not arrive until 10:30 AM, and that the dialysis center expected her to arrive by 9:30 AM to start on time. A dialysis provider staff member stated the resident had missed transportation to an appointment because she was not ready on time. The DON stated she expected residents with a 9:30 AM dialysis time to be up and ready by 8:00 AM and ready for pick-up by 8:45 AM, and that she did not know how many times this resident had been late. Staff interviews indicated that post-dialysis assessments should include vital signs, weight, and evaluation of the fistula site for thrill, bruit, appearance, and dressings, but the MAR review showed these elements were frequently incomplete, contributing to the identified deficiency in dialysis-related care and services.
Missed Dialysis Sessions and Incomplete Hemodialysis Assessments Due to Elevator Failures
Penalty
Summary
The deficiency involves the facility’s failure to provide dialysis services consistent with professional standards of practice for a resident receiving hemodialysis. The facility’s policy on care of residents receiving hemodialysis, last reviewed in May 2025, required nursing staff to complete pre- and post-dialysis assessments, including documenting pretreatment information and post-treatment vital signs and access site assessments in a hemodialysis communication book. For a resident with heart failure, chronic kidney disease, and cirrhosis who received dialysis three times per week, surveyors found that from mid-March to late April 2026, only fifteen days had dialysis sheets in the communication book, and ten of those were incomplete, missing either the pre- or post-dialysis assessment. There was no documentation elsewhere in the electronic medical record to show that these required assessments had been completed. The facility also failed to ensure that the resident consistently attended scheduled dialysis treatments due to an ongoing elevator problem. Dialysis treatment records from September through October 2025 showed that the resident was scheduled but absent on at least one occasion due to a “facility issue,” and an elevator repair invoice documented repair work on the second and third floor elevator doors in October 2025. Interviews with a former employee, the resident, nursing staff, and the receptionist/transportation scheduler indicated that the elevator frequently malfunctioned, causing residents, including this hemodialysis resident, to miss one or more dialysis appointments. The resident reported missing dialysis sessions because the elevator was down and then having to attend dialysis on consecutive days, and staff confirmed that the resident was moved from an upper floor to a first-floor unit specifically because of missed dialysis appointments related to the elevator being out of service.
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