HospitalInspections.org

Based on review of accepted standards of practice, medical record review, review of facility documents and interview, the facility failed to provide care in a safe setting when policies and procedures were not developed/implemented to collaborate/coordinate facility contract dialysis services, nor to convey pertinent information prior to discharge for 1 of 5 patients (patient #1) reviewed.

Findings were:

According to the "National Institutes of Health, Topic: Hemodialysis - NIDDK (National Institute of Diabetes and Digestive and Kidney Diseases)" found at: niddk.nih.gov, stated, "You'll have a fixed time slot for your treatments, usually three times per week: Monday, Wednesday, and Friday; or Tuesday, Thursday, and Saturday ..."

In interview on the morning of 10/14/24, in a facility conference room, staff #2 (CEO/CNO) stated, "Staff #3 (Physician) decided after seeing (patient #1) that (patient #1) would be dialyzed Friday, 8/30/24 ... No further orders were received to put patient #1 back on a Monday, Wednesday, Friday dialysis schedule ...

In interview on the afternoon of 10/16/24, in a facility conference room, staff #2, (CEO/CNO) stated, "If they had done a proper handoff, we would have been prompted that (patient #1) would need dialysis (on Monday, 9/2/24), and we would not have discharged (patient #1). We are missing order for us to verify it. No one knew patient #1 had not dialyzed (on Monday, 9/2) ..."

In interview on the morning of 10/15/24, in a facility conference room, a contract dialysis service representative stated, "(Patient #1) received a dialysis treatment on Tuesday, 8/27/24. Next treatment should have been Thursday, 8/29/24, but was pushed due to a patient coming in with STAT (administer without delay) orders for dialysis ... Nothing happened on Monday, 9/2/24 (patient #1 did not receive dialysis treatment) because patient #1 was on a Tuesday, Thursday, Saturday schedule ...On 9/3/24, the nurse from the contract dialysis service showed up at the facility, but patient #1 was already discharged."

In interview on the afternoon of 10/16/24, in a facility conference room, staff #2 (CEO/CNO) stated, "They (physicians) are not putting in own orders and not communicating between (nephrologists) and between interdisciplinary [team] members ... patients are supposed to be weighed when receiving dialysis treatments, which they are not ... We can't rely on anyone else to do weights for us."

Review of a physician order, dated 9/2/24 at 1:43 PM, for patient #1, documented: "Discharge patient in the morning ... Discharge to skilled nursing facility (SNF)".

Patient #1 was scheduled to return to his dialysis clinic "chair" on 9/4/24 (Wednesday); however, instructions to convey Patient #1's pertinent information prior to discharge were not performed/provided.

"Form: Discharge to Community," faxed (to receiving facility) 9/3/24 at 9:00 AM, for patient #1, and signed by staff #9 (facility RN), documented in part: " ... discharge teaching and paperwork given to patient, verbalized understanding. Called to receiving nurse twice, picked up the call but did not talk, notified charge nurse" was electronically signed by staff # 9, facility RN.

Review of an email communication dated 9/3/24, from facility staff # 12 to the outpatient dialysis provider, documented in part: " ... attached are clinicals for continuity of care for patient #1. (Patient #1) discharged from our hospital today and returned to (skilled nursing facility) and will be returning to outpatient dialysis clinic tomorrow ... Patient last hemodialysis (HD) treatment was yesterday [9/2/24] but the treatment sheet has not been uploaded into patient chart yet."

In interview on the afternoon of 10/16/24, in a facility conference room, staff #11 confirmed patient #1's weight upon admission to the facility on 8/24/24, was documented and communicated to receiving facility as patient #1's weight at the time of discharge. Staff #11 stated, "I'm surprised that we did not have weights for patient #1."

In interview on the afternoon of 10/16/24, in a facility conference room, staff #2 (CEO/CNO) stated, "Patients are supposed to be weighed when receiving dialysis treatments, which they are not ... We can't rely on anyone else to do weights for us ..." When surveyors requested a facility policy for the provision of contract dialysis services, staff #2 (CEO/CNO) replied that she did not find a policy regarding dialysis services in the facility's centralized database.

Review of policy titled, "Discharge Planning," revised 4/11/23, documented in part, " ... A. Interdisciplinary Collaborative Roles in Discharge Planning ... 5. Each discipline should document discharge activities in the medical record including, but not limited to: a. Discharge Instructions provided, in laymen's terms, as applicable; ... c. Clearly identify the disposition of the patient d. Communication and/or coordination with other healthcare practitioners and healthcare providers across the continuum as applicable. 6. Documentation hand-off communication of care in the medical record, noting details of receiving entity and/or individual contacted relevant to specific discipline documentation requirements."

Review of policy titled, "Patient Safety Hand off Communication, documented in part: "The primary objective of a hand-off of information between staff is to provide accurate information about a patient's care, treatment, services, current condition, and any recent and anticipated changes. The information communicated during a handoff must be accurate to meet patient safety goals. Handoffs will include the most current information available. Handoffs are interactive with both the giver and the receiver having the opportunity to ask questions and obtain information. Handoffs require verification of the received information, including repeat back or read back as appropriate to the information being communicated. ..."

Based on review of accepted standards of practice, medical record review, review of facility documents and interview, the facility failed to prepare and administer drugs and biologicals in accordance with Federal and State law, the orders of the practitioner or practitioners responsible for the patient's care when the facility did not provide dialysis according to physician orders, develop and implement dialysis procedures, nor convey changes in dialysis treatment schedule for 2 of 5 patients (Patient #s 1 and 3) reviewed.

Findings were:

According to the National Kidney Foundation article titled, "Missing Dialysis Treatment Is Dangerous for Your Health" found at: kidney.org, stated, "The amount of time you ' re on a Dialysis Machine is determined by your healthcare provider to meet your individual needs. Removing extra fluids can cause cramping, headache, or nausea, as the healthcare team try to get you back to your dry weight.
Your kidneys are also responsible for helping to control your blood pressure and for keeping a safe balance of key minerals, such as potassium and phosphorus, in your body. Missing dialysis treatments places you at risk for building up high levels of these 2 minerals:
High potassium, which can lead to heart problems including arrhythmia, heart attack, and death.
High phosphorus, which can weaken your bones over time and increase your risk for heart disease ..."

According to the National Kidney Foundation article titled, "What is Dry Weight?" found at: kidney.org, stated, "Dry weight is your weight without extra fluid. It ' s important for dialysis patient to monitor this, as extra fluid can strain your heart and lungs ... When you have kidney failure, your body depends on dialysis to get rid of the extra fluid and wastes that build up in your body between treatments ... If you have too much extra fluid in your body, you may need longer or more frequent hemodialysis treatments. There is a limit to how much fluid can safely be removed during each dialysis treatment ... Keep track of your daily weight. Keeping track of your weight is important between dialysis sessions. If you see sudden weight gain between sessions, you should tell your healthcare provider immediately ... If your weight changes, your dialysis care team will adjust your dry weight as needed."

Review of the medical record for patient #1 revealed diagnoses which included PMH ESRD and CHF (past medical history of end-stage renal disease and congestive heart failure). Patient #1 was admitted on Saturday, 8/24/24 with orders to receive dialysis Monday, Wednesday, Friday. On Tuesday, 8/27/24, patient #1 was ordered to receive dialysis Tuesday, Thursday, Saturday. Patient #1 was only dialyzed twice (on Tuesday, 8/27/24 and Friday, 8/30/24) while an inpatient in the facility between 8/24/24 and 9/3/24.

Review of a "Nephrology" Note, dated 9/2/24, documented in part: " ... Seen/examined. Not volume up. No complaints. HD (hemodialysis) later today. No new labs ..."

In interview on the morning of 10/16/24, in a facility conference room, Staff #11 stated, " ... there was a Monday holiday [9/2/24] ... I was told that our regular [contract] dialysis nurse would not be here ... it is my understanding no one showed up [to provide dialysis treatment]."

The physician ordered patient #1 ' s weight be recorded upon admission only. Patient #1 ' s weight was recorded upon admission to the facility on 8/24/24 at 2:30 PM as "65.4 kilograms (kg)" or 143.88 pounds.

Review of patient #1 ' s "Acute Hemodialysis Flow Sheet," dated 8/27/24, revealed areas in which to note patient "Pre (dialysis) weight" and "Post weight" were marked through, and a box was marked for "Weight not ordered."

Review of patient #1 ' s "HD Treatment Report" dated 8/30/24, revealed "Pre-treatment weight" and "post-treatment weight" were blank.

Patient #1 was only weighed upon admission, there were no weights completed before or after the 2 dialysis treatments. At the time of discharge, on 9/3/24 at approximately 9:00 AM, Patient # 1 ' s weight was documented as 144.4 pounds.

In review of "Form: Discharge to Community," for patient #1, faxed (to receiving facility) 9/3/24 at 9:00 AM, documented in part, " ... Weight at Discharge - 144.4 lb." which was electronically signed by staff # 9, facility RN.

In interview on the afternoon of 10/16/24, in a facility conference room, staff # 11 stated, " ... Discharge instructions are designed for when we make a referral to facility, we send all that information ... We want to make sure the patient gets dialyzed before they go, and that they [the patient] has a chair when discharged ... We won ' t let them go if they don ' t. They have to stay here until get it figured out ... I don ' t think we told [outpatient dialysis provider] patient #1 did not dialyze on Monday [9/2/24] ..."

In interview 10/16/24 at 2:00 PM, in a facility conference room, CEO/CNO stated, "Someone started "Charge Sheet" on 9/2/24 [indicating patient #1 was to receive dialysis that day], but it did not say that it [dialysis] did not happen ..." When asked about the facility ' s policy regarding weights, stated: "Facility policy to weigh at least upon admission and once a week (on Sunday). [The nurse performing dialysis] is supposed to get a weight when doing treatment, but they are not."

Patient #1 ' s weight at outpatient dialysis provider:
-post-treatment on 8/23/24 was 143.7 lbs.
-pre-treatment on 9/4/24 was 163.8 lbs.

During his inpatient stay at the facility, patient #1 had a weight gain of 20.1 lbs.

Patient #3 was admitted to the facility Thursday, 8/22/24, with orders to dialyze Monday, Wednesday, Friday. There was no physician order, but patient #3 ' s dialysis schedule was changed to Tuesday, Thursday, Saturday.

Review of clinical records documented patient #3 received dialysis Tuesday, Thursday, Saturday throughout his stay.

In interview on the afternoon of 10/16/24, in a facility conference room, staff # 2, Chief Nursing Officer/Chief Executive Officer (CEO/CNO) confirmed physician order documented patient #3 was to dialyze Monday, Wednesday, Friday, but he received dialysis Tuesday, Thursday, Saturday.