HospitalInspections.org

Based on review of facility policy and procedures, medical records review, and physician, and staff interviews, facility staff failed to follow policy when deciding to stop dialysis treatments for a patient whose guardian desired continuation of care for 1 of 1 patient records reviewed, (Patient #16).

The findings included:

Review of the policy "Patient's Bill of Rights and Responsibilities" current revised date 03/2019 revealed, "1. General Policy Statement It is the policy of (Named Health System) to respect and support patient rights, and to keep patients informed of their rights and responsibilities as patients ...3.) Policy Guidelines ...All of these activities are conducted with an overriding concern for the patient, and above all the recognition of his/her dignity as a human being ...As a patient, you have the right: a. to have cultural, personal values, spirituality, beliefs and preferences respected ..."

Review of the policy "Treatment Decisions Near the End of Life" current revised date 09/2017 revealed, "1). ...It is the policy of (Named Facility) to respect patient rights to make health care decisions near the end of life ...B. Standards for End-of-Life Treatment Decisions When patient representatives make decisions for patients who lack decision-making capacity (Named Facility) providers should employ the following decision-making standards ...2. If no such clear information is available, (Named Facility) providers should counsel and encourage the patient representative to make decisions based on what the patient would have wanted ... C. Disagreement About End-of-Life Treatment Decisions ...3. Disagreement between patient or patient representative and (Named Facility) physicians: ...Physicians are not required to provide treatments that are clearly outside the standards of care. In many situations, however, there is no established standard regarding what life prolonging measures are appropriate near the end of life. In these situations, physicians may not make unilateral decisions to continue or forgo life-prolonging measures when the patient or patient representative objects ...a. Continue compassionate communication in an effort to reach a consensus ...b. Request assistance from (Named Facility) Clinical Ethics Consultation Service ...c. Offer the patient or patient representative the option of obtaining a second medical opinion ...d. Explore the possibility of transfer to another (Named Facility) attending physician ...e. Explore the possibility of transfer to another health care facility ...f. Consult the legal department regarding the feasibility of a decision to seek judicial resolution ..."

Review of the medical record on 01/29/2020 revealed Patient #16 was a 71-year-old female admitted to the facility (Hospital C, health system facility) on 07/30/2019 after an against medical advice (AMA) discharge from a nearby outside facility, Hospital B. Further review of the admission history and physical (H&P) revealed Patient #16's medical history included in addition to end stage renal disease necessitating hemodialysis, Alzheimer's dementia. Review of MD #18's H&P note revealed, "This patient has considerable comorbidities that are expected to significantly alter the quality and duration of her life...Palliative care discussions were started at (Hospital B), but consensus could not be reached. She remains full code today..." Review of the medical record revealed Patient #16 resumed three-times-a-week hemodialysis (HD) treatments after admission to Hospital C. Review of a vascular surgery note dated 08/19/2019 at 2048 by MD #19 revealed Patient #16 experienced "persistent bleeding from AVF (arterio-venous fistula) following HD. Pressure had been held for 1.5 hours without any improvement ...This was controlled with one nylon suture." Review of a note by MD #20 dated 08/20/2019 at 1525 revealed, Patient #16 underwent "balloon angioplasty (mechanical stretching of a vessel by a balloon tipped catheter inserted and inflated within a vein or artery)" of the AVF and resulted in "resolution of the area of stenosis (narrowing) with improvement in flow ..." and inpatient HD treatments were resumed. Review of a "Progress Note" attestation by MD #4 dated 09/05/2019 at 1339 revealed "Today she remains minimally interactive. She opens eyes to voice and looks at me ...but does not speak to me ... During family meeting yesterday, available family members are (sic) not agreeable to transition to hospice care/withdrawal of dialysis at this time. Consider neuro/psych assessment ...Also consider requesting that LTACs (long term acute care facility) review pt (patient's) chart again ..." Review of a "Progress Note" by MD #7 dated 09/06/2019 at 0619 revealed, "Overnight patient found to have pulsatile blood coming from her AV fistula ...1 L (liter) of estimated blood loss ...Vascular surgery was able to suture fistula to obtain hemostasis. Patient is minimally responsive at baseline and was unable to notify staff of this complication ...She open (sic) her eyes to verbal stimulation. When asked how she was feeling she stated, 'I am feeling fine'." Review of a "Progress Note" by MD #7 dated 09/06/2019 at 1540 revealed, "I met with family ... Updated the family that the current fistula is no longer viable, and patient (Patient #16) would need alternate method of dialysis access. Discussed with them the plan to evaluate for a permacath (a two-access port catheter which is tunneled under the skin, sutured in place, and used for medium to long term dialysis access) that would potentially happen on Monday in order to continue inpatient dialysis. They expressed understanding and acceptance of this plan ..." Review of a "Progress Note" attestation by a psychiatrist, MD #5 dated 09/06/2019 at 1906 revealed, " ...With regards to capacity to accept/refuse dialysis or accept/refuse comfort care measures ...patient clearly lacks capacity to make those decisions ...Will recommend to reach out to surrogate decision maker ..." Review of a "Progress Note" by MD #6, dated 09/07/2019 at 1000 revealed, "No acute need for dialysis today ...Anticipate next treatment 9/9/19 ..." Review of a "Progress Note" by MD #8, dated 09/07/2019 at 1135 revealed, "Per vascular, AVF no longer suitable for use. Will need repair v. (versus) Ligation (sic) pending long term dialysis plan ...IR (interventional radiology) consulted for perm-cath (permacath) placement, which will likely take place on Monday, 9/9 ..." Review of a "Progress Note" by MD #7, dated 09/09/2019 at 0645 revealed, "IR unable to place permacath today. Have been told patient is scheduled to be first thing on 9/10 ..." Review of a "Progress Note" by MD #9, dated 09/10/2019 at 1650 revealed, "Was scheduled for perm cath today, however GOC (Goals of Care) discussion had in which it was decided that patient will no longer be receiving iHD (intermittent hemodialysis) inpatient or outpatient ..." Review of a "Progress Note" by MD #8, dated 09/12/2019 at 0633 revealed, "Family meeting occurred on 9/10 with (Named family members). This meeting also included nephrology, social work, and nursing staff. Family was informed that nephrology was no longer recommending inpatient or outpatient dialysis ...Furthermore no dialysis centers nor LTAC were willing to accept her ...Family was informed we would not be pursuing the permacath ...Family expressed they were not in agreement with this plan. We recommended palliative care ...however they declined. Family left the meeting stating, 'we will take care of it' ...9/11 family enacted Medicare discharge appeal ..." Review of a Care Coordination note revealed the facility was notified the family's challenge of the discharge was "lost" (rejected by a discharge review organization) on 09/12/2019 at 1658, and staff had notified Patient #16's family. Review revealed Patient #16 was discharged from Hospital C on 09/13/2019 at 1126. Review of the Care Coordination Discharge Note by a clinical social worker, CSW #11, dated 09/13/2019 at 1126 revealed, "Unaware of patient's discharge location as family stated, 'we are not disclosing that information you guys are kicking her out why do you need to know'." Record review revealed no documentation an ethics consult had been initiated for continuation of dialysis treatments during the admission.

Interview on 01/29/2020 at 1445 and again on 01/31/2020 at 1315 with a clinical social worker, CSW #11, revealed she recalled, and had worked with Patient #16 and her family. Interview with CSW #11 revealed there had been an ethics consult in August 2019 when family had expressed concerns about enteral (via tube) feeding options and aspiration risks, but she did not recall an ethics consult regarding insertion of a catheter for use in dialysis treatments. Interview revealed there had been, however, "a lot of discussion regarding dialysis and ethics." CSW #11 indicated "from the beginning the family had a different plan" than was being recommended by staff at the facility.

Interview on 01/30/2020 at 1135 with a nephrologist, MD #13 revealed, prior to admission, Patient #16 had received nephrology and dialysis services through another physician and dialysis center group. MD #13 stated "We had given her at least four weeks of treatment," and Patient #16 remained "non-verbal, contracted, and showed little interaction with staff." Interview with MD #13 revealed he believed outpatient dialysis "was not an option," which was important since one-to-one care was not possible in an outpatient setting. Interview revealed it had been more difficult than usual to develop rapport with the family because the physician group had not been involved in Patient #16's care prior to the admission. MD #13 indicated he had tried to explain to the family, the reasons he believed continuing dialysis was futile, but "they were not in agreement with the plan," and "I was not involved in that (ethics discussions)."

Interview on 01/30/2020 at 1610 with a medical service attending physician, MD #8, revealed he had spoken with the family in early September "on day four after coming on service." Interview revealed MD #8 had "sat with three people and had to keep going over care (expectations) and she (family member) said she disagreed." Interview revealed family members "did not seem to understand certain things. They got angry with me." Interview with MD #8 revealed if a dialysis catheter had been inserted, it would not have been a "permanent fix," and Patient #16's outcome would not have changed.

Interview on 01/31/2020 at 1040 with the Ethics Committee Chairman, ECC, revealed there had been an ethics consult for a feeding tube, but there was no indication a consult for continuation of dialysis treatments had been made. Interview revealed it was the committee's task to help all parties "understand the situation and find a way forward."

Group interview on 01/31/2020 at 1220 with physicians involved in Patient #16's care, MD #8, MD #13, and MD #17 revealed toward the end of Patient #16's hospitalization, "We had the (09/10/2019 family) meeting. This was the first time we were saying clearly that it was futile to continue dialysis. Family said, 'we've got it from here' and promptly left." During interview MD #8 stated "We made the decision and instead of allowing time to have the discussion, it was as if it was all over before we reached that point." MD #8 revealed he was "not aware of that specific policy (Facility's Treatment Decisions policy). I am aware of ethics policies and have called many ethics consults in the past but did not get one here." Interview revealed MD #8 had instructed CSW #11 to "let them calm down and see where things go," but the family had cancelled facility arranged transport at discharge and had made private arrangements.

Based on review of the facility policy and procedures, medical record review, and staff interviews, the facility staff failed to ensure appropriate discharge for a patient requiring discharge to a skilled nursing facility for 1 of 3 discharged patient records reviewed. (Patient #13)

The findings included:

Review on 01/29/2020 of the facility policy titled, "Continuity of Care Coordination of Discharge Plans" with a revision date of 09/2017 revealed, " ... The discharge planning program of [Facility Name] is designed to utilize the expertise of the various participating professionals in the development of a multidisciplinary plan which best meets the specific needs of individual patients ...6. Placements and Transfers to Other Residential Facilities: The Department of Care Coordination accepts responsibility for coordinating and facilitating sensitive and timely transfer of such patients to the most appropriate facility. These facilities may include but are not limited to: ... intermediate or skilled nursing facilities, rehabilitation centers or subacute care facilities."

Medical record review on 01/29/2020 of Patient #13, revealed a 39-year-old male patient that was transported to the [Facility Name] Emergency Department on 03/26/2019 at 2005 by EMS (Emergency Medical Services) after being found unresponsive. Patient #13 had a past medical history of paraplegic (paralysis of the legs and lower body) and known opioid/heroin abuse. Patient #13 was admitted to an ICU (Intensive Care Unit) on 03/26/2019 at 2146. Review of the "Progress Note" dated 09/02/2019 at 0857 revealed, "... Discharge planning issues... Currently awaiting bed availability at SNF (skilled nursing facility) vs (versus) housing to become available through the many fellows people program. ..." Review of the "Therapy Visit - Daily Note" dated 09/03/2019 at 1432 revealed "... Assessment ... PT D/C (discharge) Recs (recommendation): Inpt (inpatient) post acute therapy/low intensity (SNF) ..." Review revealed the recommendation from physical therapy was for Patient #13 to discharge to a SNF. Review revealed Patient #13 was discharged to an ALF (Assisted Living Facility).

Interview on 01/29/2020 at 1605 with SW (Social Worker) #1 revealed SW #1 remembered Patient #13. Interview revealed SW #1 arranged discharge for Patient #13. Interview revealed Patient #13 was discharged to an ALF (Assisted Living Facility).

Telephone interview on 01/29/2020 at 1542 with PT (Physical Therapist) #2 revealed her recommendation was for a Skilled Nursing Facility (SNF). Interview revealed "Inpt post acute therapy/low intensity" means SNF. Interview revealed Patient #13 required assistance from lying to sitting and from sitting to wheelchair. Interview revealed Patient #13 was "maximum assist of 2." Interview revealed Patient #13 could self-propel himself in the wheelchair.

Telephone interview on 01/30/2020 at 1300 with MD (Medical Doctor) #3 revealed the MD "did not recall knowing that Patient #13 went to an ALF." Interview revealed per the "Discharge Summary", Patient #13 needed to discharge to a SNF.

NC00156092, NC00159058, NC00154427, NC00154301, NC00157221, NC00155934, NC00157594, NC00154948