Fmc Cary Kidney Center

“PA-FREQUENCY REASSESSMENT-UNSTABLE Q MO CFR(s): 494.80(d)(2) In accordance with the standards specified in paragraphs (a)(1) through (a)(13) of this section, a comprehensive reassessment of each patient and a revision of the plan of care must be conducted- At least monthly for unstable patients including, but not limited to, patients with the following: (i) Extended or frequent hospitalizations; (ii) Marked deterioration in health status; (iii) Significant change in psychosocial needs; or (iv) Concurrent poor nutritional status, unmanaged anemia and inadequate dialysis. This Standard is not met as evidenced by: 38766 Based on a review of policies and procedures, medical records, and staff interviews, the facility’s interdisciplinary team (IDT) members failed to identify a patient as unstable and perform a monthly reassessment and a plan-of-care for one (1) of one (1) sampled patient with an extended hospitalization (Patient #2). Findings included A review on 05/28/2025 of the facility’s policy titled, “Comprehensive Interdisciplinary Assessment and Plan of Care” revised 07/03/2023 revealed “...CIA/POC for Unstable Patients: Unstable patients must be reassessed by the IDT monthly. Monthly reassessment and any POC updates related to the reason the patient is considered ‘unstable’ must be documented until the issues have been resolved or the IDT (including the patient, if possible) determines that the condition is chronic. The following are unstable criteria: a. Hospitalization of more than 15 days with discharge occurring within the last 30 days. ... or Marked deterioration in health status ... or Significant change in psychosocial needs ...” A medical record review on 05/28/2025 of Patient #2 indicated that the patient was admitted to the facility on 05/24/2017 for in-center hemodialysis treatment. A review of the record revealed the patient was admitted to the hospital on 02/28/2025 through 03/18/2025 (18 days hospital stay) with a Discharge Diagnosis of “left foot osteomyelitis.” The record revealed that the patient had his left toes amputated two weeks before the hospital admission. The patient was taken to the hospital’s emergency department for the worsening of redness and drainage. The review revealed the patient was discharged to an in-patient rehab on 03/18/2025 until 04/16/2025 (29 days in-patient rehab stay). The review indicated that the patient’s last Plan of Care (POC) was on 01/24/2025, and the patient’s status was recorded as stable. The review revealed that there was no documentation of monthly reassessments or revisions to the plan of care to consider the patient as unstable by the IDT after a hospitalization of an 18-day stay followed by an in-patient rehab stay of 29 days. An interview on 05/28/2025 at 1545 with the FA confirmed that Patient #2 had a prolonged hospitalization followed by an in-patient rehab stay. The interview revealed that the patient did not receive a care plan upon returning to the clinic because he was doing better than before his hospitalization. A follow-up interview on 05/29/2025 at 1015 with the FA revealed, after a review of the facility policy, the patient should have been deemed unstable and had a plan of care to reassess his status, at which point the provider could have made the decision to keep him unstable or deemed him stable. The FA added that the clinic utilized a computer system that identified unstable patients after a certain number of days of hospitalization. The interview revealed, “I am not sure why the patient was not flagged as unstable by the system.””