Davita Doctors Dialysis Center of Montebello

“POC-IDT DEVELOPS PLAN OF CARE CFR(s): 494.90(a) The interdisciplinary team must develop a plan of care for each patient. This Standard is not met as evidenced by: 36206 Based on interview and record review, the Interdisciplinary Team (Nursing, Social Worker, Physician, Dietitian) failed to conduct re-evaluation or reassessment and formulate a plan of care (or treatment plan) for one of one sampled patient (Patient 1), after Patient 1 was hospitalized for over a month, and returned to the facility for hemodialysis (replaces the work of the kidneys to filter waste and excess fluid from the blood) treatment. This deficient practice had the potential for the Patient’s needs not to be met. Findings: During an interview on 9/26/2024 at 1:42 pm, with the Registered Nurse (RN), the RN stated the following: Prior to Patient 1’s hospitalization in Janurary 2024, Patient 1 was receiving hemodialysis (HD) treatments on Mondays, Wednesdays, and Fridays. Patient 1 suffered a stroke (poor blood flow to the brain) and was hospitalized in January 2024. Patient 1 returned in March 2024 for HD treatment and was suffering from fluid overfload (too much fluid volume in the blood), which resulted in Patient 1 receiving an additional HD treatment on Saturdays. Patient 1 passed away in August 2024. During an interview on 9/26/2024 at 1:232 pm, with the Facility Administrator (FA), the FA stated the following: Patient 1 was hospitalized for one month and Patient 1’s condition went “south (worsened).” Patient 1 was receiving four treatments a week, instead of three, due to issues with fluid overload. Patient 1 was also having issues with housing and was at risk of being homeless. During an interview with Social Worker on 9/30/2024 at 9:01 am, the SW stated the following: Patients are required to have an initial evaluation by the Interdisciplinary Team (IDT, nursing, social work, physician, and destitution) on all new patients, after 90 days, annually, and after a patient has been hospitalized. SW stated Patient 1 was hospitalized from 1/29/2024 through 3/21/2024. Patient 1 returned to the facility on 3/22/2024. Patient 1 required a re-evaluation by the IDT which included a social worker evaluation, which assesses the patient’s needs such as, social support, insurance issues, education, cash assistance, resources for housing and transportation, and emotional support, and coping skills. SW stated Patient 1 was provided with resources for housing and cash assistance after returning to the facility after Patient 1’s hospitalization. The SW confirmed that the IDT re-evaluation or re-assessment was not done for Patient 1 upon returning to the facility on 3/22/2024, should have been done to assist Patient 1 with any needs Patient 1 may have. During a second interview with Social Worker, on 9/30/2024 at 3:27 pm, the SW stated the following: There was no current IDT Plan of Care for Patient 1, addressing needs after Patient 1’s hospitalization. The last IDT Plan Of Care was dated 12/11/2023. Patient 1 was discharged from the facility because of a prolonged hospitalization from 1/29/2024 and returned to the facility on 3/22/2024. Due to the prolonged hospitalization, the patient was considered a new patient and Patient 1 should have had a comprehensive assessment by the IDT and a new Plan of Care should have been formulated, because Patient 1’s condition may have changed. During an interview with the Facility Administrator (FA) on 10/22/2024 at 9:03 am, the FA stated the following: Patients are considered discharged or inactive if patient has not received any treatment at the facility in 30 days. When a patient returns to the facility, patient is considered to be a new patient, and a re-evaluation or re-assessment is required. The computer system should trigger the Interdisciplinary team (IDT) to conduct an assessment. The team assessment is completed by the social worker, dietitian, physician, and nursing to identify any changes in the patient’s condition after hospitalization. FA verified that the computer system did not trigger the IDT to perform an assessment. The IDT assessment and IDT Plan of Care was missed and not completed by the team. During a review of Patient 1’s “Patient Summary of Information Sheet,” the Summary indicated Dialysis began on 1/13/2020, with an Anticipated Restart Date of 3/22/2024. Renal Function Status: ESRD (End Stage Renal Disease, final stage of chronic kidney disease, kidneys stop functioning). Discharge Date: 8/26/2024. During a review of Patient 1’s “Patient Plan of Care,” dated 12/11/2023, the Plan of Care indicated the following: An IDT met. Patient (1) stable. The Plan of Care addressed topics such as Patient 1’s hemodialysis access site, anemia, fluid and blood pressure, nutrition, psychosocial (coping skills, resources), rehabilitation, and transplant options. During a review of the facility’s policy and procedure (P&P) titled, Interdisciplinary Team (IDT) Patient Assessment and Plan of Care,” dated 10/2024, the P&P indicated the following. Assessment: 1. The facility’s interdisciplinary team (IDT) consist of at a minimum, the patient or the patient’s personal representative, a registered nurse, a physician or Non-physician Practitioner (NPP)..., a social worker, and a qualified renal dietitian per CMS (Medicare and Medicaid Services, a federal healthcare regulatory agency). 2. The interdisciplinary team is responsible for providing each patient with an individualized and comprehensive assessment documenting his/her needs. The comprehensive assessment will be used to develop the patient’s treatment plan and expectations for care. 3. Assessment criteria will include, but not limited to, evaluation of: - Current health status and medical condition, including co-morbid conditions. - Dialysis prescription, blood pressure, and fluid management. - Laboratory results... - Factor associated with anemia (deficiency in red blood cells)... - Nutritional status by dietitian... - Psychosocial needs by a social worker... - Family and other support systems... - Current patient physical activity level... 7. A comprehensive re-assessment of each patient and a revision in the plan of care will be conducted...At least monthly for unstable patients including, but not limited to, patient with the following: - Extended or frequent hospitalization. - Marked deterioration in health status. - Significant changes in psychosocial needs... 15. Assessment and Plans of care for Hospitalized Patients: Patients who are hospitalized at any time during the routine expected IDT Patient Assessment and Plan of Care process will not have an assessment and plan of care completed by the IDT until the patient returns from hospitalization.”