Failure in Communication with Hospice Services
Penalty
Summary
The facility failed to maintain effective communication between nursing staff and hospice services, leading to inadequate treatment, monitoring, and continuity of care for two residents receiving hospice care. Resident #3, who had severe cognitive impairment and was receiving hospice care, experienced multiple falls and changes in condition. Despite the facility's policy requiring immediate notification to hospice staff, the hospice was not informed of these incidents, including a significant fall that resulted in a hospital visit. Interviews with facility staff and hospice personnel revealed a lack of documentation and communication regarding these changes in condition. Resident #469, who had severe cognitive impairment and was under hospice care, experienced a fall and subsequent pain, which was not communicated to the hospice in a timely manner. The resident's granddaughter was informed of the incident by the hospice nurse, not the facility, and requested a hospital transfer. The hospice nurse and social worker confirmed they were not notified of the resident's fall and subsequent condition changes, despite the facility's policy and agreement with the hospice provider requiring such communication. The facility's Director of Nursing and other staff acknowledged the expectation for nurses to communicate any changes in condition to hospice staff and document these communications. However, the lack of adherence to these protocols resulted in a failure to provide coordinated care for residents receiving hospice services, as evidenced by the incidents involving residents #3 and #469.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. (a) Immediate action(s) taken for the resident(s) found to have been affected include: The Hospice provider was made aware on of the regarding resident #3 during an in-person visit. The hospice provider was made aware on of the for resident #469 via phone call with case manager. In person communication re: between hospice provider and facility occurred on. Residents #3 and #469 are no longer residing at the facility. (b) Identification of other residents having the potential to be affected was accomplished by: All Residents receiving Hospice services have the potential to be affected. A facility-wide audit was conducted to identify all residents receiving hospice services and assess the adequacy of communication of with hospice providers occurred timely. (c) Actions taken/systems put into place to reduce the risk of future occurrence include: Starting on all Nursing staff (RNs and LPNs), including unit managers, received education on hospice care communication, proper documentation, and the importance of interdisciplinary collaboration. Nursing staff (RNs and LPNs), including unit managers, will be in-service by Any Nursing staff (RNs and LPNs), including unit managers not in-serviced by this date will be in-serviced prior to their next scheduled shift. We have no Agency staff currently. All newly hired Nursing staff (RNs and LPNs), including unit managers, will be in-service by the ADON during their orientation. (d) How the corrective action(s) will be monitored to ensure the practice will not recur: The Director of Nursing or designee will conduct weekly audits of all hospice residents' records for 4 weeks, ensuring accurate documentation and proper communication with hospice providers, followed by monthly audits of 3 hospice residents' records for an additional three months. Audit results will be reviewed in the facility's Quality Assurance and Performance improvement (QAPI) meetings, with corrective actions taken as needed. Compliance monitoring will continue until sustained improvement is demonstrated, as determined by QAPI oversight. (e) The date of compliance is