Why dialysis patient bled to death remains a mystery

[okarol]

Why dialysis patient bled to death remains a mystery

By DEAN OLSEN
STAFF WRITER

Saturday, May 03, 2008

JACKSONVILLE — An autopsy Friday failed to determine whether employee error or a defective part contributed to the bleeding death of a Cass County man in a dialysis center this week.

“Nothing’s clear on this,” Morgan County Coroner Jeff Lair said after the autopsy by pathologist Dr. Jessica Bowman at Memorial Medical Center in Springfield. “I don’t know if they’ll ever be able to tell what really happened.”

Lair decided that the unusual death of Larry Grammer, 68, was an accident and was caused by excessive bleeding triggered when a connection failed between two sections of tubing carrying Grammer’s blood during a dialysis session at DaVita Inc.’s dialysis center at 1515 W. Walnut St. in Jacksonville.

Grammer, a Virginia resident and retired state worker, was found unconscious about 7:45 a.m. Thursday with a pool of blood under his chair, Lair said. Grammer was taken to Passavant Area Hospital, where he was pronounced dead about 9 a.m. Thursday.

Lair said Grammer’s dialysis session began at 7 a.m. Thursday. DaVita staff had checked on him about 10 minutes before an alarm on Grammer’s dialysis machine went off at 7:45 a.m., Lair said. The alarm indicated a drop in pressure in the tubing.

Lair said the two sections of tubing that came apart had been screwed together. He said he didn’t have both sections to examine during the autopsy, but he said he saw no damage to the plastic tubing or the connection.

“It doesn’t look defective,” said Lair, a former paramedic. “It could have just come apart. Nothing’s perfect, and the way it works, it’s hard to tell.”

He said he didn’t find any obvious indication of employee negligence.

DaVita spokeswoman Stephanie Horn said the California-based company is continuing its own investigation.

“If there is an adverse occurrence, we take it very seriously,” she said. “Quality of care and patient safety are always the most important things.”

The Jacksonville dialysis center, which has been in operation for 23 years, remains open, she said.

The Illinois Department of Public Health will investigate the incident on behalf of the federal government, Public Health spokeswoman Melaney Arnold said.

The U.S. Centers for Medicare and Medicaid Services work with state health departments to inspect dialysis centers every three to four years. If deficiencies aren’t corrected, the centers’ funding from Medicare — which covers most dialysis patients — can be terminated.

The DaVita center in Jacksonville was last inspected in August 2006, and no deficiencies were found, she said.

Some patients and their caregivers worry that the federal government’s oversight system for dialysis centers is lax, said Roberta Mikles, a retired nurse from San Diego who co-founded the Association of Dialysis Advocates (www.assndialysisadvocates.org).

Mikles said some states don’t have the resources to inspect dialysis centers according to the recommended schedule, and some don’t follow up quickly enough to make sure that deficiencies are corrected.

She said she would like to see dialysis centers inspected at least as often as nursing homes, which undergo evaluations every 12 to 15 months.

The Illinois Department of Public Health follows up with dialysis centers within 45 days if a deficiency is found, Arnold said. Illinois has 196 dialysis centers.

Dean Olsen can be reached at 788-1543.

http://www.sj-r.com/News/stories/29731.asp

[spacezombie]

I bet no one checked on him for a long time. I bet the alarm was going on and on before they noticed. I hope this was not the case. 

[Adam_W]

If a Luer-Lok connection is secured properly, the chances of it just coming apart randomly are highly unlikely. However, so as not to immediately blame the staff, the patient may have moved his arm or something and the line may have gotten caught on something and pulled apart. The bottom line is, this was a terrible accident, and I feel for his loved ones.

Adam

[jbeany]

We had a similar incident at my center last summer.  Thankfully, they caught it before it became fatal.  The patient had to have a blood transfusion.  She always slept thru her entire treatment, and the machine didn't alarm at all.  One of the nurses spotted the pool of blood under the chair.  Scary!

[thegrammalady]

i wonder how often something like this happens that we don't hear about.

[Sunny]

How could the staff not notice a giant pool of blood under the chair?
And since they didn't, they need to be more vigilant. It shouldn't be that hard to get off your ass and do a chair check every so often.
God knows I managed plenty of chair checks when I was a teacher. So even if the tube did come apart somehow or the alarm did fail,
 a simple chair check is all it would have taken to note something was very wrong.

[flip]

It amazes me that someone would want to blame Davita for another patient death. I see a big lawsuit in the near future. How can you miss something like this?

[Sluff]

What ever the reason, someone should have noticed. That is the reason some people choose to go to a clinic rather than do home dialysis. They may feel safer that the techs and Nurses are there.

[aharris2]

I've got words: Criminally negligent homicide!!!

I see this too often: An alarm that goes ignored because "It's not my pod" and the tech for the pod one is in is on break, busy, whatever..., Nurses and techs busy socializing with each other and the patients (nice, perhaps, but the job is life and death) - they should be vigilant as they walk around the unit, looking for blood and grey patients, not to mention any other sign of distress.

Rolando almost bled to death during a bathroom trip at the unit. His fingers which were frozen into hooks at the time, hooked one of the lines and pulled it out. He bled profusely of course. He pulled the alarm and, thank God, somone came quickly (that doesn't always happen either). He was taken to the ER by ambulance because of the amount of blood lost. Later, the tech who took him off and was responsible for securing his lines tried to tell me that he had pulled his line out, suggesting that he had a death wish, thus absolving herself of all responsibility. She's no longer working there.

[okarol]

Dialysis center found to have 'deficiencies'

May 17, 2008 - 12:08AM
BY GREG OLSON
Journal-Courier

A local dialysis center is working to correct some problems so it does not lose its Medicare funding.

The Illinois Department of Public Health recently investigated DaVita Healthcare Dialysis Center, 1515 W. Walnut St., following a death that occurred there, and its investigation raised a few red flags.

"In terms of the DaVita case, there was an investigation which found some deficiencies with regards to health/safety of patients," said Peter Leonis, public information officer for the Centers for Medicare and Medicaid Services (CMS), which administers the Medicare program and works in partnership with state governments to administer Medicaid. Mr. Leonis said he could not go into specifics about the "deficiencies."

Stephanie Horn, a spokeswoman for DaVita, said the dialysis center is working closely with the Department of Public Health and CMS, and “we have submitted a plan to respond to the concerns made in their recent inspection.

 "The center remains open and has been in the community serving patients for over 23 years," said Ms. Horn. “Quality of care and patient safety are always of the utmost importance. The last inspection by the Department of Public Health resulted in a deficiency-free survey.”

The investigation of DaVita was precipitated by the death of 68-year-old Larry L. Grammer, who died May 1 from excessive blood loss, after the tubing to his dialysis machine loosened, said Morgan County Coroner Jeff Lair.

http://www.myjournalcourier.com/news/dialysis_18326___article.html/center_public.html

[flip]

If the connection that failed was on the arterial line, the alarm would sound immediately. If it was the venous line, there may not be an alarm. It depends on how the machine is set up. In my center you have to keep your access visible at all times. We have a nurse for every 4 patients and it's their responsibility to make sure nothing like this happens.

[kellyt]

What ever the reason, someone should have noticed. That is the reason some people choose to go to a clinic rather than do home dialysis. They may feel safer that the techs and Nurses are there.

That is the main reason I will choose in-center.   This is terrifying!

[aharris2]

What ever the reason, someone should have noticed. That is the reason some people choose to go to a clinic rather than do home dialysis. They may feel safer that the techs and Nurses are there.

That is the main reason I will choose in-center.   This is terrifying!

This feeling of safety is an illusion. Many alarms go unanswered and patients are ignored for what is, in my opinion, an excessive amount of time.