Resident 103 attended dialysis three times weekly through a central line surgically placed in her right chest. The facility's care plan specifically directed staff to monitor her for complications including bleeding and catheter displacement.
On the day she died, LPN 1 discovered the resident standing naked in her room with blood flowing from the red port of her dialysis catheter. The blood streamed down her chest and pooled on the floor. The clamp meant to seal the line hung open, and no protective cap covered the catheter's end.
The nurse clamped the bleeding line and left to retrieve a cap. When she returned, the clamp had come undone again. Blood was visibly flowing from the catheter.
What happened next violated every principle of emergency nursing care. Instead of maintaining continuous supervision of the bleeding catheter, staff allowed a certified nursing assistant to escort the resident down the hallway. No licensed nurse accompanied them to monitor the life-threatening bleeding.
The resident made it back to her room, where she collapsed. Inspectors found her slumped backward on her bed with her feet on the floor. Blood had leaked from the catheter onto the bedding and formed a trail on the floor where her feet had been.
She lost consciousness. Her breathing stopped. Her pulse disappeared.
Staff initiated CPR until paramedics arrived, but the resident could not be revived.
The facility's Director of Clinical Services admitted during inspection interviews that nursing staff had received no training in dialysis access emergencies. When asked about this gap on the day of inspection, the director stated that the facility expected nurses to have learned these skills during their initial licensing preparation.
This expectation proved fatal. The nurse who discovered the bleeding catheter failed to apply a hemostat when the clamp malfunctioned. A hemostat is a basic surgical instrument designed to stop bleeding by clamping blood vessels or, in this case, a failing catheter line.
In a follow-up interview, the Director of Clinical Services acknowledged that the nurse should have used a hemostat. She could not explain why staff failed to place a new cap on the central venous catheter after discovering it was missing.
The resident's care plan had documented her medical complexity. Beyond requiring dialysis three times weekly, she suffered from an irregular heart rate. The dialysis care plan, initiated specifically for her case, warned staff to watch for exactly the complications that killed her: site discomfort, infection signs, phlebitis, occlusion, infiltration, displacement, and bleeding.
Federal inspectors classified the violation as immediate jeopardy, the most serious level of harm in nursing home regulation. This designation indicates that the facility's failures created an immediate threat to resident health and safety.
The case exposes a dangerous gap in nursing home staffing standards. Facilities routinely accept residents requiring complex medical care, including dialysis patients with surgically implanted catheters. These devices carry significant risks of infection, clotting, and catastrophic bleeding.
Yet the facility provided no specialized training for staff caring for dialysis patients. The Director of Clinical Services essentially admitted that nurses were expected to handle life-threatening emergencies based solely on their basic nursing education, which may have occurred years or decades earlier.
The resident's death was entirely preventable. Proper application of a hemostat would have stopped the bleeding immediately. Continuous nursing supervision during the emergency would have prevented her unsupervised walk down the hallway while hemorrhaging.
Most fundamentally, a simple protective cap placed over the catheter's open end would have prevented the entire emergency.
The inspection report documents a cascade of nursing failures that began with inadequate training and ended with a resident bleeding to death on her bedroom floor. Each missed intervention represented another opportunity to save her life.
Instead, she died alone, collapsed between her bed and the trail of blood that marked her final steps.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Orchards of Cascadia, The from 2025-11-14 including all violations, facility responses, and corrective action plans.