Failure to Document Hospice Wound Assessments
Penalty
Summary
The facility failed to ensure that the designated interdisciplinary team member obtained the required information from the contracted hospice provider for a resident who received hospice services. The agreement between the facility and the hospice provider, dated March 5, 2021, stipulated that hospice services should be provided at the same level as if the resident were in their own home. The facility's policy, dated September 27, 2024, required the hospice provider to document pertinent information relative to each visit throughout the course of care. The resident in question had a Stage 3 pressure ulcer and was receiving hospice care. The care plan required staff to document weekly the treatment and measurements of the wound. However, there was no documented evidence of the weekly wound assessments and measurements being completed for several weeks, specifically from September 8 through November 22, 2024. This lack of documentation indicated a failure to meet the requirements set forth in the hospice agreement and facility policy. An interview with the Director of Nursing confirmed that the hospice was responsible for following the resident's wounds during their visits. However, the hospice did not provide any documented evidence of their weekly wound assessments and measurements being completed on the specified dates. This oversight led to the deficiency cited in the report.
Plan Of Correction
A communication was made to the hospice team to ensure all documentation was made available in resident 35's electronic medical record (EMR) as it relates to weekly wound assessment/measurements for the weeks of September 8 through 14, 2024; September 15 through 21, 2024; September 22 through 28, 2024; September 29 through October 5, 2024; October 6 through 12, 2024; October 13 through 19, 2024; and November 17 through 22, 2024. A sweep of all hospice caseloads was conducted to ensure all wound records of hospice services were rendered into the patient's EMR. Any issues identified were corrected at the time of discovery. The skilled nursing interdisciplinary team (IDT) and hospice IDT members were re-educated on having all records of hospice services rendered to the patient available in the patient's electronic medical record. The risk management assistant or designee will conduct audits to ensure all wound documentation of hospice services rendered is made available in the hospice patient's electronic medical record weekly X4 weeks, monthly X2 months. Identified issues will be addressed at the time of discovery. Audit results are reported to the Quality Assurance Performance Improvement committee to identify trends and further opportunities for quality improvement and needs for additional education/re-education.