CLASS AA CITATION -- PATIENT CARE
On 11/7/10, a RN recorded that a CNA reported to her that a resident had blood on his chest, abdomen and AVF (a shunt installed in an artery in the arm to allow for dialysis.) The RN called 911, gave breathing treatment and recorded his blood pressure. The RN did not record any information as to the cause of the blood, nor was there any information recorded as to any attempt to stop the bleeding. The resident was transferred to the emergency department and pronounced dead. The coroner's preliminary report indicated cause of death as "shock due to hemorrhaging." The coroner also found a hole in the resident's AVF. The CNA who reported the bleeding stated that she observed the RN walking back and forth in front of the resident's room and returning to the nurses station to check the chart or use the phone at least three times while the CNA cleaned the resident of blood. The facility staff did not assess the resident for bleeding from his AVF or apply pressure to stop the bleeding. The facility was cited for allowing the resident to bleed to death.