F0627

D

Failure to Ensure Safe Discharge Planning for Dialysis-Dependent Resident

Palos Hills, Illinois Survey Completed on 02-27-2026

Penalty

No penalty information released

Summary

The facility failed to provide a safe and orderly discharge for a resident with end stage renal disease who was dependent on renal dialysis. The resident’s admission record showed a diagnosis of end stage renal disease and dependence on dialysis, with a care plan indicating dialysis on Monday, Wednesday, and Friday and a discharge planning focus that included dialysis. An order summary reflected a discharge home order, and a social service progress note documented on the day of discharge that the dialysis time was still pending. Despite the lack of a confirmed hemodialysis chair date and time, the resident’s family chose to proceed with discharge home at 1:00 p.m., and the assistant administrator and administrator were notified. The facility’s discharge policy required Social Services to assess discharge potential on admission, meet with the resident and/or family to set up outside services and equipment, and enter a discharge summary progress note into the EMR upon planned discharge.

Interviews confirmed that the discharge occurred without a confirmed dialysis appointment. The administrator stated that the resident did not want to stay in the facility to ensure a dialysis date and time was set up and acknowledged that the resident and family were aware dialysis was not confirmed when they proceeded with discharge. The family member reported that the social worker said they would call with the dialysis date and time as soon as possible and that all paperwork was in, but the family never received a call and the resident was taken to the local hospital emergency room the following morning for dialysis treatment. The DON stated an expectation that social service staff set up all home health care services, including a confirmed dialysis date and time, and that if a resident insisted on leaving, the physician should be notified.