Involuntary Discharge of Patients - Network 13

STANDARD: 100% of involuntarily discharged patients will be reported to the Network 30 days prior to the discharge. Documentation of initial contact with the Network, synopsis of ongoing problem(s), reassessment, and efforts to resolve the problem(s) and documentation of provision of the ESRD Network 13 Patient Toll-Free number will be submitted along with the involuntary discharge notice to the patient.  

CRITERIA: In an effort to minimize the incidence of involuntary discharges, all facilities are recommended to seek Network assistance prior to discharging a patient to ensure there is recognition among facility staff of the responsibilities listed below that accompany the action of involuntary discharge and of the potential negative outcomes for the patient.

1.  NOTIFY THE NETWORK PRIOR TO AN INVOLUNTARY DISCHARGE: 

• The Network requires 30-day notification prior to the involuntary discharge of any patient to provide an opportunity for the Network Patient Services Department to review the issue(s) with facility staff, the reassessments, ongoing problem(s), and efforts that have been made to resolve the problem(s).
• The Network Patient Services Department and facility staff can explore if other actions might be utilized to prevent the involuntary discharge. 
• The facility staff should thoroughly document the patient’s behavior: steps taken to assist the patient in addressing and modification of the problematic behavior, referral assistance provided, and outcomes of those referrals. The documentation should include:
  • Conflict management steps taken by the staff in addressing any disruptive patient situations
  • Physician and medical director’s discharge orders concurring with the discharge actions
  • Documentation indicating the patient was informed of the Network 13 Grievance Procedure and was provided the patient toll-free number
• Any patient considered at-risk for involuntary discharge or transfer must be considered “unstable” triggering a comprehensive interdisciplinary team (IDT) patient reassessment due to “significant change in psychosocial needs.” Note that V767 requires that patients at risk for involuntary discharge be reassessed.
  • “Significant change in psychosocial needs” would include any event that interferes with the patient’s ability to follow aspects of the treatment plan.
• The Network Involuntary Discharge Packet is completed and required documentation is submitted to the Network for review. 

2.  TRAIN FACILITY STAFF: 

• ESRD Network 13 requires that all facility staff receive training in conflict management techniques and this training is documented and reviewed annually. The Network reserves the right to request this documentation be submitted for review.

3.  REPORT INVOLUNTARY DISCHARGES TO THE NETWORK: 

• Any discharge or transfer of a patient who has not requested such action is to be reported to the Network as an involuntary discharge regardless if the patient was transferred to another dialysis facility. While there is a mechanism in CROWNWeb for this reporting, each facility is responsible for reporting the discharge and discharge reason to the Network directly. The facility will be contacted if the discharge and reason are not reported correctly and will be required to submit the corrected information.  

 4.  INVOLUNTARY DISCHARGE SHOULD BE THE OPTION OF LAST RESORT: 

• All efforts and options need to be put forth to prevent involuntary discharges from occurring. CMS regulations need to be followed on allowable discharges (see reference: CMS Regulations).
  • If a discharge occurs, patients are given advanced notice to ensure orderly transfer or discharge. Under most circumstances, we interpret orderly transfer or discharge to require a 30-day notice and active staff assistance in locating a new facility. 
  • It is expected that a patient will not be discharged without notice and without receiving assistance in securing another unit except in cases involving physical assault, or when the patient is considered a serious threat to the safety and security of staff or other patients. 
  • If an immediate termination of services is necessary to maintain a safe environment, the patient should be:
    • Notified by certified letter
    • Given a list of facilities in the area
    • Notified of area hospitals that may provide emergency care
  • Active assistance (contacts made for the identification of available treatment space at facilities in the local geographical area, referral of patient and transmission of required medical records) for patients who have had immediate termination of services can still be provided through telephone.
  • When chronic placement is not obtained, the discharging physician and facility should work with area providers to ensure continued treatment.
  • The practice of “banning” a patient within a chain of providers is not supported.
  • Documentation of all discharge activities is required in the patient’s records.

5.  NOTIFICATiON OF THE STATE SURVEY AGENCY:

• Documentation should indicate that the State Survey Agency (SSA) was notified of the involuntary discharge or transfer. Documentation should reflect the date, time, and person the involuntary discharge or transfer was reported to.  

RATIONALE: 

The number of patients involuntarily discharged from facilities is a concern in Network 13 and throughout the country. Any ESRD patient without access to regular chronic dialysis and the necessary support services is at increased risk for morbidity and mortality. An unknown number of deaths have occurred due to lack of access to dialysis. Although the number may be small, these deaths may have been preventable. They evoke disturbing ethical questions, particularly in the case of any discharge for non-adherence.

EVALUATION:  The MRB requires the Network staff to evaluate facilities for compliance with this established standard and criteria. Compliance will be accomplished by:

           A.  Reports of involuntary discharges made to the Patient Services Coordinator and submission of  the required documentation.

            B.  Reconciliation with submitted monthly Network Patient Activity Reports indicating discharge criteria 6c.

REFERENCE: CMS regulations Section § 494.180 Condition: Governance. (f) Standard: Involuntary discharge and transfer policies and procedures.

The governing body must ensure that all staff follows the facility’s patient discharge and transfer policies and procedures. The medical director ensures that no patient is discharged or transferred from the facility unless:

1. 

1. The patient or payer no longer reimburses the facility for the ordered services
2. The facility ceases to operate
3. The transfer is necessary for the patient’s welfare because the facility can no longer meet the patient’s documented medical needs
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:
   • Documents the reassessments, ongoing problem(s), and efforts made to resolve the problem(s), and enter this documentation into the patient’s medical record
   • Provides the patient and the local ESRD Network with a 30-day notice of the planned discharge
   • 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
   • Contacts another facility, attempts to place the patient there, and documents that effort
   • Notifies the SSA 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.*

Abbreviated involuntary discharge procedure:  

Discharges that occur due to serious threat or actions where it is deemed necessary to discharge the patient without the provision of a 30-day notice. Each facility should have a procedure for abbreviated involuntary discharge that indicates:

• Behaviors and/or actions will result in an abbreviated discharge (less than 30 days)
• Notification of patient in writing regarding the decision to discharge
• Placement assistance will be provided to the patient by the facility
• Provision of a listing of hospitals providing acute dialysis care for interim dialysis care until placement can be arranged
• Efforts to be made to provide the necessary security at the facility (including those made to provide ongoing dialysis care while placement efforts are undertaken)
• Notification of the Network prior to discharge (discharge is not official until written notification of discharge is provided to patient)

RESOURCES: 

1. DPC Position Statement on Involuntary Discharge: Executive Summary (available on request from the Network)
2. DPC Toolkit http://www.esrdncc.org/index/decreasing-dialysis-patient-provider-conflict (See pages 90-97)