Failure to Coordinate Hospice Services
Penalty
Summary
The facility failed to ensure proper coordination of hospice services for three residents, leading to deficiencies in their end-of-life care. The facility's policy on hospice care, dated January 10, 2025, mandates that the resident's plan of care should include a description of services provided by the facility to maintain the resident's well-being. However, the facility did not obtain necessary hospice service orders and failed to coordinate hospice services with facility services for Residents R39, R62, and R81. Resident R39 was admitted to the facility on October 24, 2024, with diagnoses including high blood pressure, dementia, and hyperlipidemia. A physician's order dated February 17, 2025, indicated admission to hospice services, but the comprehensive care plan did not reflect that the resident was receiving hospice services. Similarly, Resident R62, admitted on September 1, 2021, with diagnoses of high blood pressure, hyperlipidemia, and dementia, had a physician order for hospice services dated October 24, 2024, but the care plan lacked coordination details, such as contact information for the hospice agency and access to the 24-hour on-call system. Resident R81, admitted on March 6, 2024, with diagnoses of high blood pressure, wound infection, and septicemia, also had a physician's order for hospice services dated February 10, 2025. However, the care plan failed to include necessary coordination details with the hospice agency. The Director of Nursing confirmed the facility's failure to ensure proper coordination of hospice services with facility services for these residents, impacting their end-of-life care.
Plan Of Correction
R39, R81 and R62 no longer resides at the facility, unable to correct. To identify other residents that have the potential to be affected, the DON/designee reviewed current residents on hospice to ensure obtain a diagnosis and order for hospice services and to ensure the coordination of hospice services with facility services to meet the needs of each resident for end-of-life care. To prevent this from happening again, DON/designee educated Social Services on the regulatory requirements of F849. To monitor and maintain ongoing compliance, the DON/designee will audit hospice residents for hospice order contains name/phone number, and diagnosis present in the care plan weekly x4 then monthly x2. Negative findings will be corrected. Ad Hoc education will be provided as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.