Resident 1 died at 8:15 p.m. from a hemorrhage at her AV fistula site — the surgically created connection between an artery and vein that allows dialysis patients to receive treatment. Staff had failed to document when she left for dialysis, when she returned, or whether they checked her vital signs or assessed the fistula site for bleeding.
The facility's Director of Nursing told inspectors the death "could have been avoided if facility staff followed the facility's policies and procedures for the care and monitoring of hemodialysis residents."
Nobody monitored Resident 1 after she returned from dialysis treatment. There was no documented evidence that staff checked on her condition following her return to the facility.
The DON acknowledged that staff failed to implement the resident's care plan interventions for AV fistula care and monitoring. The care plan had been initiated specifically to address the monitoring needs for her dialysis treatments.
Federal inspectors found the facility's policies created confusion among staff about their responsibilities. The dialysis care policy "did not clearly define the pre- and post-dialysis responsibilities of licensed nurses, the required monitoring of the residents before and after dialysis treatment, and the care and monitoring of dialysis access sites," according to the DON.
This lack of clarity resulted in what the DON described as "confusion among facility staff regarding pre- and post-dialysis assessments, the care of residents receiving hemodialysis, and the proper implementation of care plan interventions."
The facility's policy stated that staff would be "responsible for the overall care delivered to the resident, monitoring of the resident prior to and after the completion of each dialysis treatment." But the DON admitted there was "a systemic failure in the facility's processes for providing care to residents before and after hemodialysis treatment."
Staff were supposed to document when residents left for dialysis, who accompanied them, their return time, and any medications sent with them. None of this documentation existed for Resident 1's final dialysis trip.
The facility's End-Stage Renal Disease policy required staff caring for dialysis residents to receive specific training, including "the care of grafts and fistulas" and "the type of assessment data that is to be gathered about the residents' condition on a daily or per shift basis."
AV fistulas require careful monitoring because they create a direct connection between high-pressure arteries and low-pressure veins. Bleeding complications can be life-threatening without immediate intervention.
The nursing documentation policy required "concise, clear, pertinent, and accurate" records of resident status and care. For residents leaving the facility, nurses were supposed to document departure and return times "along with any medications sent."
Federal inspectors reviewed the facility's policies during their investigation and found the gaps between written procedures and actual practice. The DON's admission that the death was preventable underscored the severity of the monitoring failures.
The inspection occurred on December 26, 2025, as part of a complaint investigation. Inspectors classified the violations as immediate jeopardy, the most serious level of harm under federal nursing home regulations.
Resident 1's hemorrhage occurred because the basic safety net failed. Staff didn't document her departure for dialysis. They didn't record her return. They didn't check her vital signs. They didn't assess her fistula site for bleeding. And they didn't follow her individualized care plan designed to prevent exactly this type of emergency.
The DON's acknowledgment that "facility staff did not follow the facility's policies and protocol related to the care and monitoring of a resident receiving hemodialysis" revealed a breakdown in the most fundamental aspects of nursing home care — following established procedures to keep residents safe.
By 8:15 p.m., Resident 1 was dead from bleeding that proper monitoring might have detected and stopped before it became fatal.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Astoria Healthcare Center from 2025-12-26 including all violations, facility responses, and corrective action plans.