HospitalInspections.org

Based on medical records, policies, and interviews the facility failed to provide a safe setting for dialysis treatment in one (Patient #1) of three patients reviewed.

Findings included:

Review of the Policy titled, "Hemodialysis", # BC-HEMO-110, revision date 01/2025 ...Purpose: to provide safe in-patient hemodialysis treatment Policy: hemodialysis is performed by a skill validated hemodialysis team member ...initial hemodialysis per provider order...

Review of the policy and procedure titled, "Hemodialysis care of the patient requiring," # BC-CS-927, reviewed 03/2024...expected outcomes ...acid- based balance restored, Electrolytes, BUN, and creatine restored to baseline levels ...

Review of the policy and procedure titled, "Assessment / Reassessment of Adult Patients", # NCL0132, revision 07/2024 ...The scope of assessments and reassessments are based on the patient's diagnosis, the care setting, the patient's willingness to receive treatment, and the response to and effectiveness of care and interventions ...Reassessment A. The patient status is reassessed at regular intervals. Reassessments is triggered by changes in patient's condition or needs, change in caregiver, and change request from patient family or physician and to determine the response to effectiveness of care and interventions ...

Review of Patient #1's medical record discharge summary revealed that on 02/25/2025 at 3:54 AM he presented to the Emergency Department (ED) with past medical history of hypertension, hyperlipidemia, coronary artery disease, diet-controlled diabetes mellitus and end-stage renal disease, on hemodialysis and was experiencing progressive shortness of breath. Patient #1 was admitted to the hospital with diagnosis of congestive heart failure (CHF) in setting of dialysis patient. On 3/3/25, the medical chart notes that the patient experienced cardiac arrest. Resuscitation attempts were made however Patient #1 expired. "Cause of death is likely hyperkalemia in setting of end-stage renal disease on hemodialysis."

Review of Patient #1's Medical record orders showed that on 02/25/2025 at 10:18 AM an order for Dialysis Tuesday, Thursday and Saturday with a duration 3 hours, dialysis bath (a solution of pure water, electrolytes and salts, such as bicarbonate and sodium which purpose is to pull toxins from the blood into the dialysate) Calcium 2.5 mEq/L, Dialysis Bath Potassium (K) Sliding scale, Dialysis Bath Sodium 137 mEq/L.
Potassium sliding scale: Serum K less than 4 mEq/L use 4 mEq/dl bath
Serum K 4.0 to 4.5 mEq/L use 3 mEq/L bath
Serum K 4.6 to 6 mEq/L use 2 mEq/L bath
4 mEq/L bath contains 2.25 mEq/L Calcium

Patient #1's medical record revealed that the serum potassium (K) (a blood test) on 02/25/2025 (Tuesday) 4:45 AM resulted 4.6, 02/26/2025 (Wednesday) 4:18 AM resulted 4.6 and on 03/03/2025 (Monday) 4:35 AM resulted 6.8, a Critical High value. Normal serum potassium (K) levels are 3.5 to 5.0 milliequivalents per liter (mEq/L)

Patient #1's medical record showed that on 02/25/2025 (Tuesday) at 3:05 PM he received dialysis with a K bath of 2 mEq/L. On 02/27/2025 (Thursday) at 1:15 PM he received dialysis with a K bath of 2 mEq/L. On 03/01/2025 (Saturday) at 11:00 AM he received dialysis with a K bath of 2 mEq/L.

During an discussion on 03/31/2025 at 2:07 PM with Staff I, Educator inquired about the sliding scale of potassium and she stated there is no testing policy of potassium with the sliding scale.

During a phone interview on 3/31/2025 at 3:40 PM with Staff J, Nephrologist (medical doctor specializing in the diagnosis and treatment of kidney diseases and disorders), discussing the hospital event and a sliding scale for potassium baths for dialysis patients, she stated her expectation as a provider is for patients laboratory tests should be drawn the morning before dialysis and the Dialysis Nurse would adapt the bath used according to the scale orders. She stated we are going to change the policy to reflect that lab be drawn prior to any dialysis treatment in the acute setting.



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Based on medical records, facility documents, policies, and interviews, the facility failed to thoroughly analyze and implement appropriate corrective action 1 (Patient #1) of 1 incident reviewed.

Findings included:

Review of the facilities 2025 Quality Improvement and Patient safety Plan showed.... The risk management Department is responsible for collecting, tracking, trending and reporting events as outlined in the sentinel events/ serious event policies...Serious safety events: events of patient harm that occurred due to a deviation from an established standard of care. All reported events are analyzed for harm and potential deviation...

Review of the facilities policy and procedures titled, "Risk Management Plan" # BC-RK-123, last reviewed 01/2023 ... The Plan promotes the development of processes that identify, prevent, and mitigate organizational risks ...The Governing Board is responsible for oversight of organizational risks and assigns the responsibility for the development, implementation, and oversight of the plan to administration. Ongoing monitoring of Plan compliance and effectiveness rests with the Risk Services department ...

Review of Patient #1's medical record discharge summary revealed that on 02/25/2025 at 3:54 AM he presented to the Emergency Department (ED) with past medical history of hypertension, hyperlipidemia, coronary artery disease, diet-controlled diabetes mellitus and end-stage renal disease, on hemodialysis and was experiencing progressive shortness of breath. Patient #1 was admitted to the hospital with diagnosis of congestive heart failure (CHF) in setting of dialysis patient. On 3/3/25, the medical chart notes that the patient experienced cardiac arrest. Resuscitation attempts were made, however Patient #1 expired. "Cause of death is likely hyperkalemia in setting of end-stage renal disease on hemodialysis."

Review of Patient #1's Medical record orders showed that on 02/25/2025 at 10:18 AM an order for Dialysis Tuesday, Thursday and Saturday with a duration 3 hours, dialysis bath (a solution of pure water, electrolytes and salts, such as bicarbonate and sodium which purpose is to pull toxins from the blood into the dialysate) Calcium 2.5 mEq/L, Dialysis Bath Potassium (K) Sliding scale, Dialysis Bath Sodium 137 mEq/L.
Potassium sliding scale: Serum K less than 4 mEq/L use 4 mEq/dl bath
Serum K 4.0 to 4.5 mEq/L use 3 mEq/L bath
Serum K 4.6 to 6 mEq/L use 2 mEq/L bath
4 mEq/L bath contains 2.25 mEq/L Calcium

Patient #1's medical record revealed that the serum potassium (K) (a blood test) on 02/25/2025 (Tuesday) 4:45 AM resulted 4.6, 02/26/2025 (Wednesday) 4:18 AM resulted 4.6 and on 03/03/2025 (Monday) 4:35 AM resulted 6.8, a Critical High value. Normal serum potassium (K) levels are 3.5 to 5.0 milliequivalents per liter (mEq/L)

Patient #1's medical record showed that on 02/25/2025 (Tuesday) at 3:05 PM he received dialysis with a K bath of 2 mEq/L. On 02/27/2025 (Thursday) at 1:15 PM he received dialysis with a K bath of 2 mEq/L. On 03/01/2025 (Saturday) at 11:00 AM he received dialysis with a K bath of 2 mEq/L.

Review of the hospital documentation, dated on 03/13/2025, showed that corrective action failed to identify an area of opportunity with a potassium sliding scale with no potassium (K) levels being drawn, prior to utilization of the K sliding scale.

During a discussion on 03/31/2025 at 2:07 PM with Staff I, Educator inquired about the sliding scale of potassium and she stated there is no testing policy of potassium with the sliding scale.

During a discussion on 03/31/2025 at 2:15 PM with Staff F, Regulatory Manager regarding the discussion with the Critical Care Register Nurse (CCRN) educator and she stated, "I understand what you are saying about not having K level prior to dialysis treatment." She also disclosed that they did not identify the sliding scale and the lack of potassium level as one of the contributing factors.

During a phone interview on 3/31/2025 at 3:40 PM with Staff J, Nephrologist (medical doctor specializing in the diagnosis and treatment of kidney diseases and disorders), discussing the hospital event and a sliding scale for potassium baths for dialysis patients, she stated her expectation as a provider is for patients laboratory tests should be drawn the morning before dialysis and the Dialysis Nurse would adapt the bath used according to the scale orders. She stated we are going to change the policy to reflect that lab be drawn prior to any dialysis treatment in the acute setting.