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Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.43 DISCHARGE PLANNING was out of compliance.

A-0821 STANDARD: DISCHARGE PLAN (c)(4) - The hospital must reassess the patient's discharge plan if there are factors that may affect continuing care needs or the appropriateness of the discharge plan. Based on interviews and document reviews, the facility failed to reassess the discharge plan of one of one dialysis patients reviewed, who had a significant change in post-discharge care availability. (Patient #3)

Based on interviews and document reviews, the facility failed to reassess the discharge plan of one of one dialysis patients reviewed, who had a significant change in post-discharge care availability. (Patient #3)

Findings include:

Facility policy:

The Discharge Planning policy read, the discharge planning process will be coordinated by the Case Manager in collaboration with the patient, designated patient support caregiver, physician, and other members of the interdisciplinary healthcare team. The Case Manager will monitor, re-evaluate, and modify the discharge plan of care as indicated by patient progression, condition, and preference. The case manager or designee will initiate referrals to extended care providers, specialized ambulatory services, and/or community-based resources as applicable and relevant to the discharge plan and patient goals/treatment preferences. The Case Manager will secure acceptance for post-discharge care services as applicable to the discharge plan of care. Documentation should include details of acceptance of the service/provider and information shared to obtain acceptance for post-discharge care needs. The Case Manager will confirm and/or assist with the arrangements for the following, but not limited to, in preparation for discharge: arrange for outpatient services such as dialysis, infusions, outpatient therapies, and Coumadin clinics as applicable.

1. The facility failed to ensure outpatient dialysis treatment was arranged and confirmed before discharging the patient. As a result, the patient was discharged without secured acceptance from an outpatient dialysis facility.

A. Document review and interviews revealed outpatient dialysis treatment was not established for Patient #3 before the patient was discharged. This resulted in Patient #3 missing an ordered hemodialysis treatment.

i. Medical record review for Patient #3 revealed the patient had end-stage renal disease (when the kidneys no longer work) and required hemodialysis (a treatment performed to clean the blood and remove waste, extra fluids, and toxins from the blood). According to Patient #3's medical record, Patient #3 received hemodialysis treatments every Monday, Wednesday, and Friday.

According to the progress note entered by Physician #1 on 1/20/25 at 5:43 p.m., Patient #3 required outpatient hemodialysis after the patient was discharged. Additionally, the progress note revealed Case Manager #2 had arranged outpatient dialysis treatment for the patient, and discharge was anticipated for the patient on 1/21/25.

ii. The case management notes and addendums were reviewed and revealed Patient #3 was discharged without an established outpatient hemodialysis treatment schedule.

a. On 1/22/25 at 10:54 a.m., twenty-four hours and 58 minutes after Patient #3 had been discharged, Case Manager #2 entered a case management addendum note.

According to the note, on 1/20/25 at 11:06 a.m. and 3:36 p.m., Case Manager #2 called the outpatient hemodialysis contact center to obtain the hemodialysis treatment schedule for Patient #3. However, during the call, the contact center could not provide confirmation hemodialysis treatment was established for Patient #3.

Further review of the addendum note revealed on 1/21/25 at 8:18 a.m., one hour and 38 minutes before Patient #3 was discharged, Case Manager #2 called the outpatient hemodialysis contact center again and attempted to obtain confirmation of a hemodialysis treatment schedule for Patient #3. During this call, the contact center informed Case Manager #2 that outpatient hemodialysis treatment was still not confirmed for Patient #3. However, the patient was documented as discharged at 9:56 a.m.

iii. On 3/4/25 at 2:30 p.m., an interview was conducted with Case Manager #2. Case Manager #2 stated they performed the discharge planning evaluation, oversaw patient care coordination, and ensured any post-discharge care services were arranged and confirmed before patients were discharged.

However, Case Manager #2 stated before Patient #3 was discharged, outpatient hemodialysis treatment had not been confirmed. Case Manager #2 stated they had expected to receive a confirmation of the dialysis treatment schedule shortly after Patient #3 had been discharged. Case Manager #2 stated the outpatient hemodialysis contact center told them Patient #3 could be discharged even though the patient did not have a confirmed hemodialysis treatment schedule. Case Manager #2 stated they had not notified Patient #3's physician about the lack of a confirmed outpatient hemodialysis treatment schedule and did not reassess the discharge plan.

Case Manager #2 stated they did not receive a confirmed outpatient dialysis treatment schedule for Patient #3 until 1/22/25 at 3:14 p.m. Case Manager #2 stated because the facility discharged Patient #3 before outpatient hemodialysis was confirmed, the patient did not receive their scheduled hemodialysis treatment on 1/22/25. Case Manager #2 further stated that without dialysis treatment, the patient experienced a risk of toxin and fluid buildup, which could lead to severe complications such as electrolyte imbalances, high blood pressure, organ failure, and potentially life-threatening conditions.

The interview with Case Manager #2 contrasted with the facility's Discharge Planning policy, which stated the Case Manager would arrange and confirm outpatient dialysis services in preparation for patient discharge. The Case Manager would also ensure acceptance of post-discharge dialysis care as required by the patient's discharge plan.

a. On 3/6/25 at 8:01 a.m., an interview was conducted with regional case manager (Regional Manager) #3. Regional Manager #3 stated the discharge planning process included establishing outpatient dialysis services. Regional Manager #3 stated patients who required outpatient dialysis should have a confirmed start date, clinic location, and confirmed scheduled dialysis treatment time. Regional Manager #3 stated dialysis treatments were life-sustaining medical treatments, and without them, patients could experience severe complications and significant harm.

However, when asked whether this occurred for Patient #3, Regional Manager #3 stated that after reviewing Patient #3's medical record, outpatient dialysis treatment had not been established before the patient was discharged. Regional Manager #3 stated the discharge plan for Patient #3 should have been reassessed. Regional Manager #3 stated there was no evidence in Patient #3's medical record indicating the physician had been informed outpatient dialysis treatment had not been confirmed.

Upon request, the facility was unable to provide a formal process or policy case management staff were to follow to ensure dialysis patients were not discharged without a confirmed hemodialysis treatment schedule.