Fresenius Medical Care of Mid-Wilshire

“GOV-INVOL DISCHARGE PROCESS REQUIREMENTS CFR(s): 494.180(f)(4) The medical director ensures that no patient is discharged or transferred from the facility unless - (4) The facility has reassessed the patient and determined that the patient’s behavior is disruptive and abusive to the extent that the delivery of care to the patient or the ability of the facility to operate effectively is seriously impaired, in which case the medical director ensures that the patient’s interdisciplinary team- (i) Documents the reassessments, ongoing problems(s), and efforts made to resolve the problem(s), and enters this documentation into the patient’s medical record; (ii) Provides the patient and the local ESRD Network with a 30-day notice of the planned discharge; (iii) Obtains a written physician’s order that must be signed by both the medical director and the patient’s attending physician concurring with the patient’s discharge or transfer from the facility; (iv) Contacts another facility, attempts to place the patient there, and documents that effort; and (v) Notifies the State survey agency of the involuntary transfer or discharge. (5) In the case of immediate severe threats to the health and safety of others, the facility may utilize an abbreviated involuntary discharge procedure. This Standard is not met as evidenced by: 46238 Based on interview and record review, the facility failed to ensure an Involuntary Discharge Process (IVD, a facility-initiated discharge that did not originate through the patient ’ s verbal or written request, and/or is not in alignment with the patient ’ s preferences and stated goals for care) was conducted in accordance with Federal regulations for one patient (Patient 1). The facility failed to attempt, implement, and document abusive behavior plan of correction efforts to resolve/change Patient 1 ’ s behavior prior to serving Patient 1 with Involuntary Discharge Notice. This deficient practice violated Patient 1 ’ s rights and had the potential to compromise Patient 1 ’ s health and well-being. Findings: During a review of Patient 1 ’ s medical record (MR) titled, “Patient Discharge Letter,” dated 12/18/2024, the MR indicated, Patient 1 was served “Notice of Discharge” based on disruptive and abusive behavior impairing the delivery of care and informing Patient 1 of the facility ’ s inability to no longer provide dialysis ( a type of treatment that helps the body remove extra fluid and waste products from your blood when the kidneys are not able to) serves after January 18, 2024. During a review of Patient 1 ’ s medical record (MR) titled, “Hemodialysis Agreement, “dated 5/25/2023, the MR indicated, Patient 1 began dialysis treatment with the facility on 5/23/2023. During a record review of Patient 1 ’ s medical records, dated 7/24/2023 and 11/15/2023, the MR indicated, Patient 1 was served two letters titled, “Letter for Resolving the Concerning Behavior,” addressing multiple behavioral incidences at the facility. During a review of Patient 1 ’ s medical record (MR) titled, “Provider ’ s Rounding Note-Comprehensive Hemodialysis,” dated 10/31/2023, the MR indicated Patient 1 was non-compliant, was “unstable” (any patient at risk for transfer or discharge must be considered “unstable” and had psychological issues). During an interview on 1/19/2024, at 1:10 p.m., with Facility Administrator (FA), FA stated, Patient 1 was served IVD letter on 12/18/2023 based on series of multiple disruptive events caused by Patient 1 at the facility. FA stated, multiple times, Patient 1 demonstrated disruptive behaviors such as aggressive outbursts, non-compliance with the facility ’ s rules, threatening and verbally abusing staff, breaking into other patient ’ s cars, refusing post-treatment assessments, raising voice at staff, fist threatening staff, refusing to follow infection control rules, and other behaviors that caused disruption of the facility ’ s treatment order. FA further stated, the facility received many complaints from the staff that they did not feel safe to provide care to Patient 1. FA further stated, numerous times, the facility attempted to approach Patient 1 ’ s behavior and educate Patient 1 about the behaviors, but all attempted communication to resolve Patient 1 ’ s behavioral issues were not effective, and Patient 1 continued to demonstrate disruptive behaviors and refused to change to comply with the facility ’ s policies. During a review of Patient 1 ’ s medical record (MR), dated 5/25/2023 through 12/18/2023, the MR indicated, no documentation of the facility ’ s efforts to resolve the problem of the disruptive behavior such as Interdisciplinary Team (IDT, designed with the purpose of supporting the health and well-being of. participants in a collaborative, structured, and person-centered way) meetings with plan of correction and techniques to use for staff and patient to work on behavior, schedule changes, community resources and mental health referrals, behavioral contracts and on-going re-assessments of interventions including Patient 1 ’ s response to each step taken and the IDT re-assessment of the situation was recorded in Patient 1 ’ s medical records. During an interview on 2/5/2024, at 2:20 p.m., with Network Social Worker (NSW, working at End-Stage Renal Disease (ESRD Network 18, an organized Network, dialysis and transplant providers can coordinated patient referral and access to resources in a more efficient manner), SNW stated, the facility did not attempt to notify In-Network of Patient 1 ’ s behavior issues, did not provide documentation regarding corrective actions/interventions implemented by the facility in order to limit the disruptive behavior and did not demonstrate complete and comprehensive re-assessment and revision of the plan of care for Patient 1 for potential IVD if Patient 1 was considered “unstable”. During a review of the facility ’ s policy and procedures (P&P) titled, “Disruptive Patient Behavior and Use of Behavioral Agreement,” dated 4/12/2012, the P&P indicated, “All incidents involving disruptive behavior must be immediately reported to the Team Leader Clinical Manager, Social Worker, and the Medical Director. The IDT determines the need for a comprehensive interdisciplinary assessment to determine the root cause of the behavior and what changes, if any, are needed to the plan of care. Any patient at risk for transfer or discharge must be considered “unstable” and reassessed by the interdisciplinary team. The plan of care should be revised or adjusted, to demonstrate interventions or resources agreed upon by the patient or determined necessary by the disciplinary team to resolve barriers or other issues contributing to the disruptive behavior. Documentation should be made in a progress note, as an update in the Comprehensive Interdisciplinary Assessment (CIA) and Plan of Care (POC) and should include documentation of the patient ’ s disruptive behavior, all interventions to diffuse or address patient behavior, and outcome of these efforts.” During a review of the facility ’ s policy and procedures (P&P) titled, “Disruptive Patient Behavior and Use of Behavioral Agreement,” dated 4, 12/2012, the P&P indicated, “A Behavioral Agreement is a tool that should be considered for cases in which the patient ’ s behavioral has escalated beyond the ability to be handled by the informal resolution process. Behavioral agreement should be individualized to the behaviors that the patient is exhibiting that are considered disruptive or potentially dangerous to the safety of the patient, other patients, staff or facility. The behavioral Agreement should define what responsibilities or expectations the patient will need to meet or continue to receive services in the facility. Responsibilities of the IDT in working with the patient to achieve success such as weekly meetings with the MSW, consultation outside councilors, monthly meetings with the team to review progress, etc., should be in included in the Behavioral Agreement as well.””