Dialysis Care: Hidden Risks in Nursing Homes
Dialysis care is life-saving, but when performed in nursing homes, it can come with hidden dangers that put residents at serious risk. In this episode, nursing home abuse lawyer Rob Schenk sits down with guest Nikki Chambers to discuss the unique challenges of dialysis in long-term care facilities and how to ensure it’s done safely.
Chambers:
Falls are a really huge problem when you shift that much fluid and the that many electrolytes in a short amount of time, which I know three and a half hours doesn’t sound short. You can feel dizzy, lightheaded, falling once they get back to the care facility is a big concern. Even them falling in the dialysis unit can be a big concern.
Intro
Schenk:
Hey, out there. Welcome back to the Nursing Home Abuse Podcast. My name is Rob. I’ll be your host for this episode. Today, we’re talking all about dialysis care, what it is, and what are some of the common pitfalls for when nursing home residents receive it? We’re not having that conversation alone. We have the fantastic Nikki Chambers on to walk us through that process.
We had the fantastic Nikki chambers. Nikki Chambers is President and CEO of Chambers Medical Legal Nurse Consulting, LLC. Nikki is a master’s degree prepared nurse with a post master’s in business and teaching nursing. She gained extensive experience in the hospital setting, working in various positions and units, including medical, surgical ICU, dialysis and nursing hospital administration.
Her experience in teaching facilities gives her a unique insight into how hospitals and medical teams run and what should and should not occur, and we are so happy to have her on the show. Nikki, welcome to the show.
Chambers:
Thank you so much for having me on. I appreciate it.
What is dialysis?
Schenk:
Sometimes I’ll start the episode off with a softball question. This episode will be no different. So the softball question for you, Nikki, is to walk us through what is dialysis? What is that treatment, and what is it treating?
Chambers:
Okay, so that’s a great question. So we have these organs in our body called the kidneys, and they filter out all of our waste products and extra fluid on board.
And when people have complications with their kidneys and they’re not working optimally, they need an assistive measure, an artificial kidney, if you will, to clean their blood and to take off. Any of that extra waste and fluid without dialysis, these patients become fluid overloaded, which means that they can’t breathe very well.
It starts impacting both respiratory and cardiovascular systems as well as those waste products build up in their blood and they can become toxic and end up in the hospital. So dialysis, there’s different modes of dialysis. Pretty much most is hemodialysis that you would see, which is actually putting needles in somebody’s fistula and removing their blood, washing it with the filter, and then sending it back to them in a clean way so that their kidneys obviously are, just aren’t doing their job.
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Who oversees dialysis?
Schenk:
What are the most common clinical conditions that would make someone a candidate for dialysis? What are the typical diseases or problems that would require it.
Chambers:
So people can have genetic issues where their kidneys just don’t function very well, but usually that’s pretty isolated.
Usually what we see is people that have a lot of other comorbidities, they’re a diabetic, they have cardiovascular issues that impede their kidney function and or they’re a smoker. There’s all these other things that come in together that make them a higher risk for end stage renal disease. Medications can do it too, but putting those all together, your typical clientele in the nursing home are not gonna be just your having a genetic predisposition for it. Usually they’re gonna have a lot of other comorbidities that make ’em really sick patients to deal with.
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How do nursing homes handle dialysis care for residents?
Schenk:
And typically, is dialysis the type of treatment that is provided at a nursing home or is this something that is done somewhere else?
Chambers:
It’s usually done someplace else. However, that being said, there are some nursing homes that do peritoneal dialysis, which that is a different mode of dialysis where there’s a catheter in your stomach. But those nursing home nurses have to be trained in order to do that exchange of putting fluid into that person’s abdomen and then draining it out.
They have to have specialization in that, so there’s not many nursing. That will do that type of thing just because it’s one more thing that they need to be able to be trained in, and they have to work really closely with the nephrologist and the dialysis unit to make sure that those things are being done sufficiently.
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Schenk:
When the resident is in the dialysis clinic. They’re going through the dialysis treatment. Walk us through what we see. Are they, is this in a, are they sitting in a chair? Are they in a bed? Is there, the machines are allowed walk us through that process.
Chambers:
So there’s different units based on the need that some residents may not be ambulatory.
They may come in a wheelchair or they may be transported from the nursing home in a bed. And so the setup of the dialysis units has flexibility for that. A majority of those stations, per se, are chair machines, and it’s a big open area. But we do have to take in account for those patients that do come in beds as well as those people that may be on some sort of restriction.
They’re on isolation protocol or they can’t be out in the open with other people. There’s the variety of those stations available, but usually what in a dialysis unit is you see a dialysis. Like a desk in the middle where the nurses and techs are at, and then an open unit where they can see all of the machines, because that’s a requirement.
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You have to have eyes on patients. You can’t have ’em behind closed doors necessarily. You have to have eyes on to make sure that you’re monitoring for any of those complications that may occur. People can exsanguinate in dialysis, meaning like their needles can pop out and they could be pumping out blood.
Really quickly. And so we have to have eyes on them. And yes, there are a lot of alarms and dialysis, so it can be noisy and beepy. Typically a resident will come in, they’ll get weighed as soon as they come in because we need to know since their last treatment, how much fluid have they retained because we have to establish what we call a dry weight.
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You and I, we have kidneys that function, and so we have a pretty constant weight because our kidneys are doing their job and we go to the bathroom throughout the day. These guys. Their kidneys aren’t working, so they’re not urinating at all. So they can build up, say somebody gets dialysis Monday, Wednesday, Friday from their Monday treatment to their Wednesday treatment, they may gain six pounds of fluid.
And so we need to know where they came in at. Measure where they were last time and figure out how much fluid we need to pull off in that treatment. So they get weighed, then they get put in their dialysis chair or bed they have an assessment, and then we start our dialysis treatment.
Schenk:
How long does the typical, I guess this is a two-parter, how often does the typical resident need to go to dialysis, and typically, how long does dialysis take once you’re there?
Chambers:
Okay, so a typical person just. Run of the mill three times a week minimum. Okay. There’s usually not less than three times a week. And then once they’re there, they’re sitting in that chair for three and a half to four and a half, maybe five hours at a time. So this is a part-time job for them coming to dialysis and then you have to transport them and everything else.
This is pretty much their life. A dialysis patient, they come to dialysis and then they get transport transported back at the dialysis center.
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What are common signs of dialysis neglect in nursing homes?
Schenk:
Where are the common, what are the common ways in which that process can be messed up? Like where are the common pitfalls in receiving dialysis at the dialysis clinic?
Chambers:
Oh, there’s a lot. It’s a very technical process, it can happen with somebody removing too much fluid. So you come in, you get weighed and they say you’re six pounds up, and maybe they take more than that. Okay? So that’s number one. You can remove too much fluid. Number two these settings on the machine can be wrong.
So somebody comes in and their potassium’s really high and they have to be put on a special bath. To wash that blood to get it back to a normal level that can be wrong. Also the actual placement of the needles. If somebody has a fistula, those can get dislodged and the needles can come out. That’s another issue.
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There are air can get in the line. So if you’re talking about having two needles in your arm, one’s pulling blood, one’s pushing blood back in, that’s clean. The machine itself is a closed circuit, but it can get air in it. So an air bubble going right back into the patient’s system can cause an error embolism.
There’s a lot of things that can go wrong with dialysis, and that’s why we just have to keep a really close eye on them to ensure that they’re getting the treatment that they need and that they’re being monitored appropriately. After dialysis falls are a really huge problem when you shift that much fluid and the that many electrolytes in a short amount of time, which I know three and a half hours doesn’t sound short, but.
If you’re removing six pounds of fluid off and shifting all those electrolytes, you can feel dizzy, lightheaded. So falling once they get back to the care facility is a big concern. Even them falling in the dialysis unit can be a big concern.
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Why do some nursing home residents need ICU-level care?
Schenk:
That’s a lot of serious issues that can go on at the center. So typically who’s there? Are these CNAs, are these nurses? Are there physicians at the dialysis center typically?
Chambers:
It depends on the setup of the dialysis unit. If it’s attached to a a hospital, if it’s in a hospital type setting, even though it’s an outpatient clinic, there may be doctors roaming through, but a majority of the time, regardless of the setting, you’re gonna have dialysis technicians and then you’re gonna have registered nurses that are overseeing the dialysis technician’s job.
So those are usually the main two that are there. The dialysis, nephrology. Team, they have to come and see the patient at least once a month. They have to come in and do their assessments, do their rounds, look at all of their labs, that kind of stuff. But you’re not routinely gonna see a nephrologist wandering through the dialysis center on a regular basis.
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Schenk:
Once the resident is back at the nursing home having received dialysis. You mentioned that falls are a potential risk. What are some of the others? Problems that you see once the resident is back at the facility.
Chambers:
So there are again, a number of things. These g, these are not healthy people. Let’s just like hone that in. These people usually have lots of other comorbidities, and so when they get back, not only are we worried about falls, but then we have to make sure that they’re eating the appropriate diet, which doesn’t sound like it’s a big thing, but when your body’s not able to get rid of those toxins, you’re eating a bunch of bananas and your potassium’s gonna go up, and that’s gonna cause co problems with your heart.
So making sure they’re on the exact diet, which. If you’ve ever had a renal diet, they are gross. Everything that you’ve been told about what a healthy diet is. The opposite is true for dialysis. People say eat whole wheat bread, no dialysis. Patients have to eat white bread if they’re gonna eat white bread, brown rice versus white rice, things like that.
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They just have to have a very strict diet, which is not super flavorful. Two, they have to limit their fluid intake. They can’t just be guzzling it down because then they’re. Fluid levels are gonna balloon up. Other things that they are really prone for in a nursing home setting are wounds. So already you’ve got this person that’s already at risk for wounds being in a nursing home setting, but then you make them, their kidneys have a big portion with albumin and that production and the ability to keep albumin in your body.
So when you have a low albumin, you’re gonna be at a higher risk for. Getting wounds that don’t heal, that are difficult to deal with, and then you get infections in them. So these patients just need to have a lot of care and attention given to them.
Schenk:
I guess I never considered the nutritional aspect of that where you’re, not whole wheat, white bread, that kind of stuff, reducing the fluids.
That’s really interesting. So that if you can, why is, I understand the fluid retention, I get that, but I’m trying to understand like what difference does it make, whether you would have wheat bread or white bread.
Chambers:
It’s the nutritional components in it. Because your kidneys, which usually would be ex pulling extra whatever is in there out it’s not able to do that.
And so you just have to decrease some of those extra nutrients, I guess you could say, that are in. Specific kind of foods, like they can’t eat strawberries. They can’t, there’s just a whole list of things that they cannot eat. If they do choose to eat them, then they have to be on other medications to bind the phosphorus that’s in those foods or whatever the case may be.
And that’s something that we struggle with having patients in nursing homes, is that they’re not getting the appropriate diet, they’re not having their fluids restricted. And on top of both of those things, then they don’t make it to their dialysis session. Somebody decides that transport’s not available today, so you’re not gonna get to dialysis.
That’s a huge risk for patients. They can’t go that long in between. They’re gonna end up back in the ICU.
What are the biggest risks for dialysis patients in nursing homes?
Schenk:
If the dialysis patient either doesn’t get dialysis in a timely fashion, or perhaps they’re drinking too much liquid or they’re not getting the proper diet, how does that typically, how does that typically present? Like what are the signs and symptoms that has occurred?
Chambers:
So for fluid wise, you would see that there’d be difficulty breathing. You would also see the veins in their neck. They would get distended they would get full. You’d be able to see them poking out, meaning that they just had too much fluid on board.
If their potassium is too high, they can get headaches, they can get weak. They can get dizzy. They can start having chest pains and end up with a cardiac event that way too. There’s lots of different ways that they can present with that.
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How can families ensure proper dialysis and ICU care for loved ones?
Schenk:
And in the last kind of minute or so Nikki, what if you had a family in front of you that had a loved one in a nursing home that was receiving dialysis, what advice or what would you tell them?
Chambers:
One, I would tell them that they need to be involved in that, in their loved one’s care, to make sure that these basic things are being done. The diet is correct, that people aren’t bringing them in, treats that they’re not supposed to be getting watching their fluid intake. And then probably most.
Above everything else is that they need to come to dialysis and they need to come to dialysis when they don’t feel good, because that’s usually an indication that they need dialysis. Whereas somebody else, if we’re sick and we don’t wanna go to work that’s different. This is their job. When they feel crappy, they have to come because there’s usually something wrong.
And we’ll draw labs when they get there to see what’s making them feel so bad. And maybe that means that we have to call the nephrologist and have their prescription for dialysis adjusted. But more than anything, making sure that your loved one comes to dialysis on a regular scheduled, that they don’t skip.
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Schenk:
Well, Nikki we really appreciate you coming on the show and sharing your knowledge with us today.
Chambers:
No, I appreciate it. Thanks for having me on,
Schenk:
Folks. I hope that you enjoyed this episode and found it educational. If you have an idea for a topic that you would like for me to discuss, please let me know.
If you have an idea for a guest that you’d like for me to talk to, please let me know that as well. As always, I beg you on my on my hands and knees. To get a nursing home, these podcast mug, I don’t wanna have to give a hundred of these mugs to goodwill. You know what to do at just for residents or TikTok or just anything like, I don’t care stick your head out your office window and yell out.
Rob, I want a coffee mug. I’ll give you one. No, no rules. Just like Thunder Road. New episodes of the Nursing Home Abuse podcast come out every single week on Monday. And with that folks, we’ll see you next time.
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