Davita Bakersfield Oak St Dialysis

“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: 35649 Based on interview and record review, the dialysis center failed to follow their policy and procedures titled, “Patient Behavior Agreements, 30-day Discharge, Involuntary Discharge, or Involuntary Transfer,” or “Schedule 3.1 Physician Duties” when one of one sampled Hemodialysis (mechanical process using an artificial kidney [dialyzer] to remove toxins and waste when the kidneys can no longer function normally) patient (Patient 1) was discharged from the dialysis facility and care of the Nephrologist (medical doctor specializing in kidney disease) without ensuring dialysis services were available for Patient 1. This failure resulted in Patient 1 without a nephrologist to manage her hemodialysis, the loss of dialysis treatment at a dialysis center, and the need for Patient 1 to go to the hospital for emergency dialysis treatment. Findings: During an interview on 1/13/24 at 8:15 a.m. with Patient 1, Patient 1 stated she was a dialysis patient currently residing at a skilled nursing facility. Patient 1 stated “The dialysis center denied me of the treatment I need to save my life. The nurse practitioner discharged me from her care. I do not have a place to go. No one will accept me at the dialysis. They are putting my life in danger. I need my dialysis treatment.” During an interview on 1/12/24 at 10:55 a.m. with Registered Nurse (RN) 1, RN 1 stated [Patient 1] was a resident of a skilled nursing facility (SNF) and an in-center hemodialysis patient who gets dialysis treatment every Tuesdays, Thursdays, and Saturdays, third shift, from 11:45 a.m. to 3:15 p.m. RN 1 stated Patient 1 exhibited behaviors and was not compliant with treatment. RN 1 stated [Patient 1] signed herself off renal diet, had an altercation with another dialysis patient, and had issues with yelling when she did not get her way. RN 1 stated one time [Patient 1] had an issue with the transportation driver because Patient 1 started smoking while she was on oxygen. RN 1 stated she was not sure if the nephrology group did not want the patient and discharged the patient from their care or if [Patient 1] dismissed the nephrologist group of their services. During a concurrent interview and record review on 1/12/24 at 11:08 a.m. with Facility Administrator (FA), Patient 1’s Plan of Care, dated 11/16/23, was reviewed. Patient 1’s Plan of Care indicated, “”Positive behavioral issued continued. Transfer of care to MD 1.” FA stated the Nurse Practitioner (NP) discharged Patient 1 from her care on 10/19/23. [Patient] 1 was transferred to the care of another nephrologist (MD) 1. FA stated her understanding was [Patient 1] was accepted at Dialysis Center 2 and was just waiting for a chair time at Dialysis Center 2. During an interview on 1/12/24 at 11:33 a.m. with Medical Social Worker (MSW), MSW stated because of [Patient] 1’s attitude, behavior, and profanity (language that is considered socially offensive due to being vulgar, obscene, or irreverent). MSW stated she met with NP, and NP told her she no longer wanted to deal with Patient 1. MSW stated NP decided she could not continue caring for [Patient 1] so NP told Patient 1 she would no longer be caring for her. MSW stated there was no written and signed “behavior agreement” with [Patient 1] that she was aware of and there was no Patient Care Conference conducted with the patient. During a concurrent interview and record review on 1/12/24 at 11:45 a.m. with FA, Patient 1’s “Patient Responsibilities & Standards of Conduct (PRSC),” dated 5/5/23, was reviewed. The PRSC indicated, “11. I am responsible for treating other patients, visitors, and facility teammates with consideration and respect. I will not engage in any behavior that endangers, threatens, or harms others, or use profanity.” FA stated this is what is expected of every patient, and this was discussed with [Patient 1] upon admission. During an interview on 1/12/24 at 12:10 p.m. with FA, FA stated the dialysis facility was not discharging Patient 1 from the dialysis center because of her behavior. FA stated Patient 1 did not have a nephrologist to manage her dialysis treatment here. FA stated Patient 1 needed a physician’s order from the nephrologist to be able to continue dialysis at this dialysis center. FA stated Patient 1 had to find a nephrologist who has privileges to practice at this dialysis center to continue to get dialysis treatment here. During an interview on 1/16/24 at 12:04 p.m. with Clinical Coordinator (CC) CC stated [Patient 1] exhibited behaviors such as, if [Patient 1] did not get what she wanted she would have an outburst of anger, she did not want her face touched, she did not want her blood pressure taken, she wanted us to challenge her dry weight. If Patient 1 gained two kilograms (kg-a unit of measure), [Patient 1] wanted us to remove four kilograms off her dry weight. CC stated we (referring to dialysis staff) were willing to take care of her, but she did not have a nephrologist to manage her dialysis treatment; therefore, we also had to release her from the dialysis center. CC stated, there were many patients here with behavior issues, but we learned to adapt to them and care for them. During an interview on 1/16/24 at 12:36 p.m. with NP, NP stated [Patient 1] started yelling and screaming when we were having a care plan meeting and educating her regarding her diet. [Patient 1] became very upset when she was informed to limit her diet intake. NP stated Patient 1 had not threatened her (NP), but NP felt threatened. NP stated [Patient 1] had been having repeated episodes of yelling and screaming and the behavior was not acceptable. NP stated at that moment she knew she could no longer care for [Patient 1] and decided to terminate her service and discharge [Patient 1] from her care. NP stated she made it clear with Patient 1 that NP would no longer be her nephrologist and that Patient 1 had to find another nephrologist to care for her. NP stated she discussed her decision with the Medical Director (MD), and he agreed with her decision to discharge Patient 1 from their care. NP stated MD had not spoken with [Patient 1]. During a review of the facility’s letter to Patient 1, dated 10/26/23, the letter indicated, “MD has informed the facility that MD will be discharging you from his care on 11/19/23. Therefore (sic), since he will not be providing medical treatment to you, we will have to discharge you from our facility thirty days (sic) from the date of this letter. The dialysis center could not dialyze you without physician orders from the nephrologist who is credentialed and has privileges to practice at this dialysis care site ...Unless another nephrologist at this dialysis center will accept you as their patient, we will need to discharge you effective 11/25/23. Signed by FA.” During an interview on 1/16/24 at 12:52 p.m. with NP, NP stated the nephrology group MD 2, who was providing Patient 1 her nephrology care, refused to accept her. MD 3’s nephrology group also did not want to take the patient due to her behavior. During a concurrent interview and record review on 1/16/24 at 1:15 p.m. with CC, Patient 1’s Care Plans under the section of Psychosocial, dated 7/6/23, 8/17/23, and 10/5/23 were reviewed. The Care Plan Goals indicated, “Continue to work with patient and team to minimize impacts of behavior on dialysis. Timeframe: 6 months. Provide psychosocial counseling as indicated.” CC was unable to provide documentation of Patient 1’s behavior that needed to be addressed in the care plan except for the above statement. CC stated the goal was six months to assist Patient 1 improve behavior but was not adhered upon as Patient 1 was discharged from the nephrologist care within three months without prior notice of the cause /reason for discharge in writing. CC stated, “We (referring to facility) did not follow the correct process.” During a concurrent observation and interview on 1/16/24, at 1:33 p.m. with NP in the conference room, NP telephoned MD 1 to find out about the status of the patient. NP stated MD 1 informed her Patient 1 had not been accepted at Dialysis Center 2 due to reports of behavior issues. NP stated Patient 1 goes to the hospital for dialysis once a week only. During a concurrent interview and record review on 1/16/24 at 1:48 p.m. with NP, the facility’s policy and procedure addressing “First Letter of Concern (letter notifying the patient of specific details of behavior and concerns the facility has regarding patient behavior),” dated 10/2023, was reviewed. NP was unable to provide documented evidence the facility had issued a “First Letter of Concern” prior to sending Patient 1 the “30-Day Notice of Involuntary Discharge.” NP stated she was not aware of the “First Letter of Concern.” NP stated the facility had not issued the first letter of concern. During an interview on 1/16/24 at 1:50 p.m. with MSW, MSW stated there was no first letter of concern issued to the patient. During an interview on 1/16/24 at 2:33 p.m. with MSW, MSW stated when Patient 1 left here we thought she had a specific dialysis center to go for her dialysis treatment. During an interview on 1/16/24 at 2:34 p.m. with CC, CC stated he also thought Patient 1 had a chair time in another dialysis center. Dialysis Center 2 called him for orders, so he thought Patient 1 had been accepted at Dialysis Center 2. During a review of NP’s Comprehensive Encounter (CE), dated 10/19/23, the CE indicated, “Patient has been repetitively rude with team including Provider, SW, and Dietician (sic). Patient gained 2.9 kg (kilograms, a unit of measure) since last visit, so started educated (sic) patient about fluid intake and dietitian mentioned that she talked to patient’s dietician (sic) at the skilled nursing facility (SNF) and patient got agitated stated, ‘who gave you permission to talk to dietician (sic) at SNF without my permission.’ Explained to patient that sometimes SNF’s dietician (sic) at clinic and other times, dialysis center dietician (sic) contacts SNF ‘s dietician (sic) to coordinate care. Patient got further agitated and started being rude and loud. Had conversation in the past but patient continues to have behavior issues. Gave 30-day notice in presence or (sic) SW and Dietician (sic) for patient to change Nephrologist group. Clinic FA aware ...” During a review of the “Notice of Termination of Physician-Patient Relationship (NTPPR),” dated 10/24/23, the NTPPR indicated, “The purpose of this letter is to notify you that you are no longer a patient of the nephrology group and will no longer be seen by your assigned nephrology providers MD and NP. You are strongly encouraged to engage the medical services of another provider, and it is suggested that you work with your health plan immediately to identify a suitable in-network nephrologist for your ongoing and future medical needs ...signed by the Medical Director. During a review of the facility’s policy and procedure (P&P) titled, “Patient Behavior Agreements, 30-Day Discharge, Involuntary Discharge, `or Involuntary Transfer, “dated 10/2023, the P&P indicated, “3. If the patient’s behavior continues to be disruptive to the facility, but is non-threatening to others, the patient should receive a First Letter of Concern. This letter will be written in collaboration with your Risk Manager and will provide specific details of the patient’s behavior and concerns the facility has regarding the patient’s behavior. During a review of the facility’s P&P titled, “Schedule 3.1 Physician Duties,” [undated], the P&P indicated, “Patient Discharge and Transfers. Medical Director shall: b. Assure interdisciplinary team (IDT-a group of health care professionals with various areas of expertise who work together toward the goals of their patients) adheres to involuntary patient discharge/transfer policy. c. Direct the IDT, including the attending physician, in the appropriate management of the patient with disruptive behavior, including non-adherence, threatening behavior, or non-threatening behavior. Assures that the IDT properly documents incidents of disruptive behavior, follows the [dialysis center] policy and procedure in addressing patient’s behavior, and documents the patient’s response in the medical record. Assure that the IDT has completed each of these steps prior to any involuntary discharge or transfer.””