Lack of Coordinated Hospice Care and Documentation
Penalty
Summary
The facility failed to ensure coordinated communication and availability of required hospice documents for a resident receiving hospice care. The hospice services policy indicated that hospice staff should conduct assessments, develop a hospice plan of care, and maintain it in the medical record for interdisciplinary staff access. However, the facility did not have a hospice plan of care, election forms, physician certification of terminal illness, or clinical notes for the resident in question. The resident, who was admitted with a terminal diagnosis of dementia and age-related osteoarthritis with a pathological fracture of the femur, had elected hospice benefits, but their current care plan lacked specific hospice responsibilities or interventions. Interviews with facility staff revealed a lack of communication and documentation regarding hospice services. A Licensed Practical Nurse (LPN) stated that nurses assess residents at shift change to determine hospice status, but there was no specific hospice binder for the resident. The social services staff confirmed that hospice documents were not scanned into the resident's record. Additionally, the hospice nurse admitted to not leaving the resident's plan of care or visit notes at the facility, further contributing to the deficiency in hospice care management.