Failure to Coordinate Hospice Services for Resident
Penalty
Summary
The facility failed to properly coordinate hospice services for a resident, identified as Resident R12, who was receiving end-of-life care. The facility's policy on providing end-of-life care requires that if a resident opts for hospice services, the plan of care must include the resident's underlying diagnoses and maintain communication with the hospice provider. However, the clinical record for Resident R12, who had been diagnosed with high blood pressure, diabetes, and hypokalemia, showed a physician order for a hospice referral but lacked a diagnosis related to the need for hospice services or an order to admit the resident to hospice care. Additionally, the comprehensive care plan for Resident R12 did not demonstrate coordination with hospice services, as it failed to include contact information for the hospice agency or instructions on accessing the hospice's 24-hour on-call system. This deficiency was confirmed during an interview with the Registered Nurse Assessment Coordinator, who acknowledged the facility's failure to obtain the necessary diagnosis and order for hospice services, as well as the lack of coordination between hospice and facility services to meet the resident's end-of-life care needs.
Plan Of Correction
R12 diagnosis and care plan were updated to reflect the hospice diagnosis and information. Other current hospice residents will be audited by DON or designee for documentation. DON or designee will audit hospice residents to ensure facility documents diagnosis and information in Care Plan as appropriate, in house diagnosis order and coordination of services weekly for 4 weeks then monthly for 2 months. Licensed nurses will be educated on the expectation of ensuring facility documents hospice diagnosis and information in care plan as appropriate by DON or designee. Audit results will be reviewed through the monthly QAPI process/meeting.