Failure to Coordinate Advanced Directives with Hospice and Guardian
Summary
The facility failed to coordinate advanced directives with hospice and a guardian in a timely manner for a resident who was reviewed for hospice care. The resident, who had diagnoses including Bipolar Disorder, Dementia, and Schizoaffective Disorder, was documented as cognitively intact and had expressed a desire not to live anymore to the Medical Director. Despite this, the resident's POLST form indicated a full code status, and there was no documentation of discussions with the state guardian regarding changes to the advanced directives. The Medical Director had ordered a hospice evaluation due to the resident's refusal to eat and failure to thrive, and the state guardian was informed of the clinical situation and consented to hospice services. However, there was a lack of communication and documentation regarding the resident's expressed wishes and the need to update the POLST form. The resident was admitted to hospice, but the hospice nurse noted that the resident's full code status was not addressed until the resident began declining, and the state guardian confirmed that no prior conversations about advanced directives had occurred. The facility's Director of Nursing assumed that the resident was a DNR upon hospice admission, but there was no confirmation from hospice that discussions with the guardian had taken place. The Social Service Director also did not pursue discussions about advanced directives. The hospice nurse initiated a conversation with the state guardian about the resident's code status only after the resident's condition worsened, highlighting the facility's failure to ensure timely coordination of advanced directives with hospice and the guardian.
Penalty
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A facility failed to maintain coordinated hospice care plans for two residents. One resident with dementia, ASHD, and PVD had a care plan that still referenced a prior hospice and lacked the current hospice provider, hospice visits, supplies, DME, and covered meds; the MDS also did not document hospice services. Another resident with HTN, MDD, and schizoaffective disorder had a hospice care plan that lacked visit frequency, supplies, meds, and DME details, and the hospice binder was incomplete. Staff interviews confirmed the missing hospice coordination information.
Failure to Document Hospice Collaboration in Care Plan: A resident with dementia, cognitive communication deficit, and myasthenia gravis was receiving hospice services, but the care plan did not include the frequency of hospice visits, the care hospice would provide, or the medications and equipment hospice would supply. Staff stated hospice-related information should be listed on the care plan, and the facility policy called for coordination of care with hospice staff.
A resident receiving hospice services had no IDG meeting notes in the hospice binder since hospice start of care. The hospice RN said the notes were never requested, while facility staff, including the DON and Administrator, were unaware of the required binder contents or lacked a system to ensure the binder was complete, despite using it for care coordination and order review.
A resident with cerebral infarction, DM, tracheostomy, dysphagia, and a G-tube was receiving hospice services, but the facility’s care plan did not include the frequency and type of hospice support visits, supplies, or medical equipment. The plan only addressed medication administration, pain monitoring, notification of hospice for condition changes, and DNR status, while staff stated the care plan should reflect care provided by both the facility and hospice.
Hospice care coordination and care plan deficiencies were identified for a resident with DM and COPD who was receiving hospice services. The RNCM did not know what hospice information belonged in the care plan or which staff were responsible for coordinating with hospice, and the DNS acknowledged there were no designated staff members identified to communicate with hospice representatives. The resident’s care plan also did not include hospice-related information, including the Hospice Plan of Care.
The facility failed to coordinate hospice care and keep hospice binders current for two residents receiving hospice services. One resident with dementia had a hospice binder missing recent IDG meeting documentation and an updated care plan, while another resident with stroke, anxiety, and depression did not have the most up-to-date hospice medication list. Interviews confirmed the hospice binder was expected to contain current orders, care plans, IDG notes, and medication information for continuity of care.
Missing Hospice Coordination and Care Plan Information
Penalty
Summary
The facility failed to ensure a coordinated plan of care was developed and available for two residents receiving hospice services. For one resident with dementia, arteriosclerotic heart disease, and peripheral vascular disease, the record showed hospice enrollment and a later change to a current hospice provider, but the care plan still referenced the previous hospice and did not identify the current hospice provider, the services hospice would provide, hospice staff visits, supplies, medical equipment, or medications covered by hospice. The resident’s MDS also lacked documentation that hospice services were being received, and the medical record did not show coordination of care between the facility and the current hospice provider. For another resident with HTN, major depressive disorder, and schizoaffective disorder, the record showed hospice services were in place and the resident had moderately impaired cognition with disorganized thinking and inattention. The care plan stated the resident was on hospice and included general comfort and ADL support measures, but it did not include how often hospice staff would visit, what supplies and medications hospice would provide, or what DME hospice would provide. The hospice provider binder also lacked a complete plan of care with required information, including the most recent recertification order and related details. During observations, one resident was seen in a Broda chair being assisted with lunch, and the other was seen in a Broda chair getting ready to receive noon medications. Staff interviews confirmed the missing hospice coordination information. An Administrative Nurse stated the facility should have a hospice care plan to coordinate with hospice services and acknowledged the current hospice information was not in the care plan. A CNA stated staff usually relied on the nurse to explain what hospice provided, and a nurse stated the hospice book should contain the information from the hospice POC and that the resident care plan should reflect the same information.
Failure to Document Hospice Collaboration in Care Plan
Penalty
Summary
The facility failed to ensure collaboration with the hospice provider for a resident with cognitive communication deficit, dementia, and myasthenia gravis. The resident’s EMR documented a diagnosis of myasthenia gravis, and the Quarterly MDS showed a BIMS score of 12, indicating moderately impaired cognition. The resident had received hospice services, and the care area assessment noted staff would assist with activities of daily living as needed and therapy would work to increase functional mobility. The resident’s care plan included interventions for pain, restlessness, agitation, constipation, and other symptoms of discomfort, along with instructions to notify hospice of significant changes, clinical complications, need for emergency transfer, or death. However, the plan did not include the frequency of hospice staff visits or the care they would provide, and it did not list the medications and equipment to be provided by hospice. Staff interviews indicated the hospice-related information should be included on the resident’s care plan, and the facility’s hospice coordination policy stated care would be coordinated with hospice staff to promote the resident’s highest practicable well-being.
Missing Hospice IDG Documentation and Care Coordination
Penalty
Summary
The facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for a resident receiving hospice services, including communication with the hospice medical director, the resident’s attending physician, and others involved in care. The resident was an elderly female admitted with a primary diagnosis of dementia and had an order to admit to hospice on 06/10/2026. A significant change MDS reflected severe cognitive impairment with a BIMS score of 03, and the care plan dated 06/16/2026 identified the need for hospice services with hospice staff assisting the facility in care for the resident. Record review of the resident’s hospice binder on 07/29/2026 showed there were no Interdisciplinary Group (IDG) meeting notes in the section designated for them since the start of hospice care. The hospice RN stated she had never been asked to bring IDG meeting notes to the facility and explained that the IDG meetings were used by providers to collaborate on the resident’s plan of care, orders, and goals. Facility staff, including RN B, Medical Records, the DON, and the Administrator, stated they were unaware of what documents were required in the hospice binder or did not have a system to ensure the binder was complete, although they acknowledged the binder was used for coordination of care and expected IDG meetings to be included.
Hospice Care Plan Lacked Coordination Details
Penalty
Summary
The facility failed to ensure coordinated care and services between the facility and hospice for one resident who was receiving hospice services. The resident’s EMR documented diagnoses of cerebral infarction, DM, tracheostomy, and dysphagia. The Quarterly MDS documented that cognition was not assessed, the resident was dependent on staff for all ADLs, received tracheostomy care, had a G-tube, and received hospice services. The resident’s care plan dated 06/02/2026 included interventions to administer medications as ordered, monitor for verbal and nonverbal cues of pain, intervene accordingly, notify hospice of any changes in condition, and noted a DNR. However, the care plan lacked the frequency and type of support visits, supplies, and medical equipment provided by hospice. The resident was admitted to hospice on 09/06/2025, and the facility had a hospice plan of care in a communication book dated 06/04/2026. An Administrative Nurse stated she was new to the position and would update the care plan with the information required related to hospice care, and another Administrative Nurse stated the care plan should reflect the care provided by both staff and hospice. The facility’s Hospice Program policy stated that the facility should collaborate with hospice, the nursing home, and the resident/representative on a coordinated care plan in the medical record.
Hospice Care Coordination and Care Plan Deficiencies
Penalty
Summary
The facility failed to ensure there was a designated staff member responsible for collaborating and communicating with hospice representatives, and the resident’s care plan did not include the hospice plan of care for 1 resident receiving hospice services. Resident 2 was admitted to the facility in 1/2026 with diagnoses including diabetes and chronic obstructive pulmonary disorder. An Election of Benefits and Informed Consent document showed the resident was admitted to hospice services on 5/24/26. Review of the care plan showed it did not include hospice-related information, including a Hospice Plan of Care. During interviews, Staff 6, the RNCM, stated she did not know what information needed to be on the care plan for residents receiving hospice services and did not know which staff members were responsible for collaborating and coordinating with hospice representatives for Resident 2. Staff 6 acknowledged that Hospice Plan of Care information was not included in the resident’s care plan. Staff 2, the DNS, also acknowledged the facility did not have designated staff members identified to communicate and collaborate with hospice representatives for Resident 2 and that Hospice Plan of Care information was not included in the resident’s care plan.
Hospice Documentation and Care Coordination Lapses
Penalty
Summary
The facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for residents receiving hospice services, including communication with the hospice medical director, the attending physician, and others involved in care. For Resident #4, who was re-admitted with diagnoses including dementia, muscle weakness, anxiety, and depression, the quarterly MDS indicated severe cognitive impairment and that the resident was on hospice services. The care plan identified a terminal prognosis and hospice services, with interventions focused on comfort and adjusting ADLs to the resident’s changing abilities. Record review of Resident #4’s hospice binder showed that it did not contain the last two IDG meetings or an updated care plan. The hospice RN stated the binder should contain supporting documentation such as the face sheet, election form, code status, certification of terminal illness, plan of care, and medications, and that documentation should be updated after IDG meetings. She reviewed the binder and noted the last IDG meeting in the binder was from 06/18/26 and the last care plan was from 02/22/26, while an IDG meeting from 07/02/26 was not in the binder. She stated she did not know why the updated care plan or IDG meeting was missing. For Resident #3, who was re-admitted with diagnoses including stroke, anxiety, and depression, the quarterly MDS showed severe impairment in cognitive skills for daily decision making and that the resident was receiving hospice services. The care plan indicated hospice services for stroke and cooperation with the hospice team to meet the resident’s needs. Record review showed a physician order for sertraline and a hospice medication list printed on 06/29/26 that listed sertraline 50 mg daily for depression, but the facility failed to obtain the resident’s most up to date hospice medication list. Interviews with the hospice nurse, LVN, DON, and administrator confirmed that the hospice binder was expected to contain current hospice documents and that updated information was to be provided by hospice for continuity of care.
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