Patient Dies From Dislodged Dialysis Catheter

This case takes place in New York and involves the care of an elderly man in a nursing home who was left unattended during a hemodialysis treatment. The patient was started on dialysis treatment and was left unattended at which point a dislodged hemodialysis catheter went unnoticed until the patient was completely exsanguinated. The patient’s roommate was pressing the call button for 20 minutes but no one responded to the calls for help.

Question(s) For Expert Witness

What is the proper protocol involved in monitoring a patient who is receiving hemodialysis and what would be the normal response time to a call for help from a room buzzer in a nursing home facility?

Expert Witness Response E-000418

When a patient is receiving hemodialysis they need to have continuous monitoring. This is a practice that is standard for all dialysis units and/or bedside dialysis procedures in acute care hospitals. The normal response to a call should be within a few minutes meaning 5 minutes or less. There are no regulations as to the specific time frame but a reasonable amount of time is acceptable, certainly not 20 minutes.