Kindred Transitional Care and Rehabilitation - Bay View
516 Willow St. Alameda, CA 94501
Citation Number: 020009078
Citation Date: 3/5/12
Violation Date: 11/7/10
Class: AA
Penalty: $75,000.00



Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.

The facility failed to provide services to ensure Resident 1's highest practical physical condition when the facility did not provide care when Resident 1 was bleeding which resulted in Resident 1 bleeding to death.

Record review on 12/20/10 showed that the facility admitted Resident 1, a 74-year old, on 10/16/10. Resident 1 had diagnoses that included kidney disease. His kidneys did not adequately remove waste, salts and water from his body and Resident 1 was treated with artificial kidney treatments (hemodialysis) three times each week; on Monday, Wednesday, and Friday.

Resident 1 had an arteriovenous fistula (AVF) in his upper left arm. The AVF had been created by a surgeon. In the upper arm, under the skin, a large artery had been connected to a large vein so that a large amount of blood flowed rapidly. The AVF was necessary to perform hemodialysis treatments.

According to radiological studies of AVF fistulas and success for hemodialysis treatments, "successful fistulas," had an average blood flow rate in AVF of, ''780," milliliters (ml) every minute." (Blood flowed at a rate of approximately 1.6 pints every minute.) [Reference: Radiology, October 2002, Hemodialysis Arteriovenous Fistula Maturity: US Evaluation, pages 59 - 63] Blood flow rates in mature devices typically may reach up to 2000 ml/min. but more typically they are 800-1200 ml/min. [Reference: "Clinical Dialysis" 4th edition; 2005 Nissenson, Fine]. "If an AVF bleeds, apply direct pressure until the bleeding stops. Rationale: Bleeding can be a life threatening emergency." Reference: "Textbook of Basic Nursing," 9th edition, 2008 Lippincott Williams & Wilkins.

Resident 1's nursing care plan, titled, "Kidney Dialysis: Potential Problems," dated 10/18/10, instructed that the nurse was to monitor and check the AVF every shift. There were no interventions for bleeding included in the plan.

Review of nurse's progress notes, dated 11/7/10 at 12:30 a.m., showed an entry that recorded RN A's assessment of Resident 1's condition; he was pale and weak. RN A gave Resident 1 a breathing treatment and recorded his blood pressure as 110/80, pulse=70, temperature=96.4 and respirations=24.

The Medication Administration Record (MAR) records, for the date 11/7/10, showed the initials of RN A to indicate that RN A gave Resident 1 a breathing treatment of Acetylcysteine (mucolytic agent: loosens up thick mucus) at 1 a.m. ยท

Nurses notes, at 2:35 a.m. on 11/7/10, showed that RN A recorded that a Certified Nurse Aide (CNA 1) told her that there was blood on Resident 1's, "chest, (left AVF) shunt and abdomen." Resident 1, "was breathing," but RN A was unable to measure his blood pressure or an oxygen saturation level (amount of circulating oxygen in the blood). Facility staff made a, "911," telephone call to transfer Resident 1 to a hospital emergency department and RN A documented in the nurse's notes the administration of another breathing treatment to Resident 1.

RN A did not record any information as to the cause of blood on Resident 1's body, nor was there any information recorded as to any attempt to stop bleeding.

Review of the ambulance emergency response team report, dated 11/7/10, indicated the emergency response team arrived at the bedside of Resident 1 at 2:56 a.m. Paramedic A recorded that the response team found Resident 1 with, "blood on the bed and his bandages. "Paramedic A recorded that a CNA had told him that there was, "blood everywhere ..." Resident 1 went by ambulance to the hospital emergency department (ED) and arrived at 3:12 a.m.

A review of hospital ED records, dated 11/7/10, showed that on arrival Resident 1 was. "pulseless," and not breathing. " ...the patient (Resident 1) was pronounced dead at 3:22 a.m."

The death of Resident 1 was referred to the Alameda County Coroner. Coroner Autopsy Examination Findings, dated 11/10/10, included examination of Resident 1's AVF. "There is an (oval shaped opening) defect, measuring 3/4 inch in length ... " "The opening leads into the (vessel) ... no other abnormalities are noted." There was a hole in Resident 1's AVF.

During an interview on 12/28/10 at 11:00 a.m. Paramedic A stated a call was received from the facility on 11/7/10 concerning a resident, "who was vomiting blood." Paramedic A stated he found Resident 1 lying in bed, looking pale, skin cool to touch, sweating and with an abnormal breathing pattern. Paramedic A stated "...there was no blood in (Resident 1's) mouth which is not consistent with vomiting blood." Resident 1's left arm bandage was soaked in blood.

On 12/28/10 at 11:a.m. during an interview, Emergency and Fire Response Captain H stated that (Resident 1) was all cleaned up but had a blood soaked bandage on his left arm where the shunt was. He noted that the bed sheets were clean but there were blood soaked sheets on the bathroom floor. A bandage on Resident 1's left arm was blood soaked. The nurses were, "vague," about what happened and the story kept changing about when the resident was last seen by facility staff.

The Coroner stated in an interview on 12/20/10 at 8:08 a.m., that his preliminary report indicated that Resident 1 died on 11/7/10 from shock due to hemorrhaging (excessive bleeding).

During an interview on 12/27/10 at 2:23 p.m., Police Officer 1 stated he did an investigation because Resident 1 was dead on arrival to the hospital. Review of Police Officer 1's investigative report of the interview with RN A dated 11/7/10, indicated that RN A stated that she failed to identify the source of Resident 1's bleeding and had not lifted, changed, removed or touched any portion of the access shunt device dressing. Digital photographs taken by the Police Officer showed several blood soaked linens and a bloody bandage from Resident 1's left upper arm where the access device was located.

In an interview on 12/20/10 at 2:19 p.m. RN A confirmed that she did not apply direct pressure to the bleeding AVF and that she did not check Resident 1's AVF during her work shift or contact the physician regarding the observed change in Resident 1's condition. She stated "I was exhausted. I made up the vital signs and did not give a breathing treatment as documented at 1 a.m. I didn't know where the blood was coming from." RN A was unable to identify the signs/symptoms of hemorrhaging and stated, "I don't know ... I am blank."

During an interview on 12/23/10 at 3:54 p.m., CNA 1 said she took a break at 2:00 a.m. and returned at 2:30 a.m. to check on Resident 1 and found a lot of blood around the left side of his body. CNA 1 stated she noted Resident 1 was, "breathing big breaths," so she immediately called RN A. She said RN A came into the room, took one look at Resident 1 and left to call 911. During this time, CNA 1 said she observed RN A walking back and forth in front of Resident 1's room and returning to the nurses' station to check the chart or use the phone at least three times while she (CNA 1) cleaned Resident 1 of the blood.

Facility staff did not assess Resident 1 for bleeding from the AVF and did not apply pressure to the bleeding AVF.

During an interview on 12/20/10 at 1:53 p.m., the facility's Executive Director stated that the facility had a Policy and Procedure (P& P) titled "Bleeding Control" dated 4/28/09, which indicated that firm direct pressure was to be applied to the site of the injury and pressure was to be maintained until the bleeding stops.

In an interview on 12/20/10 at 3:09 p.m., Resident 1's attending physician stated she would expect the staff to do a full assessment of Resident 1's pale and weak condition, notify the physician and apply a gloved hand or use a towel to control the bleeding.

The nephrologist, (a physician specializing in kidney disorders) during an interview on 12/21/10 at 9:56 a.m., stated he would expect the staff to put pressure if there was bleeding at the AVF.

In an interview on 4/4/11 at 3:00 p.m. the Staff Developer Coordinator (SDC) who was responsible for staff training, confirmed there was no training for care of a hemodialysis dependent resident during RN A's orientation. The SDC stated that she eventually gave staff a mandatory dialysis in-service, but RN A was always too busy to attend the meeting. The SDC was unable to provide any documentation which validated a staff in-service training of care of the dialysis dependent resident prior to 11/7/10.


The facility failed to assess the condition of Resident 1 to determine the cause of bleeding and did not apply pressure to the hemorrhaging AVF thus allowing Resident 1 to bleed to death.

These violations presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result and was a direct proximate cause of the death of the patient.