Orchards Of Cascadia, The

jeopardy to resident health or safety

irregular heart rate.A Dialysis Care Plan initiated on [DATE], documented Resident #103 had a central line in her right chest used by dialysis, and she attended dialysis every Monday, Wednesday, and Friday.

The Care Plan directed staff to monitor Resident #103 for complications such as site discomfort, signs and symptoms of infection, phlebitis, occlusion, infiltration, displacement, and bleeding.The facility's I&A report documented that on [DATE], LPN #1 found [Resident #103] standing naked with her dialysis catheter leaking blood from the red port only it was flowing onto the floor and down her chest due to the clamp the line with the red end was unclamped and there was no end cap. LPN #1 clamped the line, left to obtain a cap, and returned to find the clamp unclipped again and blood was visibly flowing from the line.

The resident was then escorted down the hallway by a CNA without continuous licensed nurse supervision of the access site.

Bleeding occurred in the resident's room [Resident #103] was slumped back with her back on the bed and her feet were on the floor.

There was blood noted coming from the catheter and had leaked onto the bed and it was also noted on the floor in front of where her feet were followed by loss of consciousness, absent respirations and pulse. CPR was initiated until EMS arrival.The facility was unable to provide evidence that the nursing staff had been trained or deemed competent in responding to dialysis access emergencies. On [DATE] at 3:08 PM, the Director of Clinical Services (DCS) stated that the facility had not provided such training and expected nurses to have learned these skills during their initial licensing preparation. In a follow up interview on [DATE] at 5:00 PM, the DCS acknowledged that the nurse should have applied a hemostat when the clamp failed and could not explain why a new cap was not placed on the CVC.

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