Failure to Coordinate Advanced Directives with Hospice Services
Summary
The facility failed to ensure that advanced directives were properly coordinated with hospice services for a resident receiving end-of-life care. Resident 28, who had multiple diagnoses including occlusion and stenosis of the right posterior cerebral artery, metabolic encephalopathy, dementia, schizoaffective disorder, borderline personality disorder, bipolar disorder, and aortic stenosis, was initially documented as a full code according to a physician's order dated November 25, 2024. However, a subsequent physician's order on February 11, 2025, indicated that the resident was to receive hospice care, and the hospice's initial plan of care dated February 10, 2025, indicated a Do Not Resuscitate (DNR) status. Despite this change, the facility was not informed of the updated DNR status until February 28, 2025. During an interview, the facility's administrator acknowledged that the hospice provider was responsible for communicating any changes in orders, including code status. However, the hospice provider failed to notify the facility of the change in Resident 28's code status to DNR. The administrator confirmed the existence of a Physician Orders for Scope of Treatment (POST) form, signed on February 10, 2025, indicating the DNR status, which the facility was unaware of until the administrator contacted the hospice on February 28, 2025. The facility's policy on advanced directives did not include guidelines for communication between hospice providers and the facility to ensure timely updates of new orders.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Missing Hospice Election and Certification Documents: The facility failed to coordinate hospice care planning and ensure a resident’s hospice binder contained the election/cancellation/update form and the physician’s certificate of terminal illness. A resident with schizophrenia, metastatic breast cancer, and severe cognitive impairment was receiving hospice services, and the DON stated the hospice company was responsible for the binder after the missing forms were identified and faxed.
A resident receiving hospice care had missing and outdated hospice documentation, and staff gave conflicting accounts of where the hospice plan of care was kept. Surveyors found only hospice contact sheets in a binder, while the paper chart contained a hospice plan that had just been printed and still listed the resident as living at home with home health services. The DON said hospice notes were expected after each visit and that floor nurses and unit managers were responsible for keeping the hospice plan updated, but the facility could not produce the resident’s hospice binder or visit notes.
A facility failed to keep hospice binders current and coordinated for two residents receiving hospice services. One resident’s binder lacked the latest med profile, recent IDG notes, and recertification paperwork, and it did not include current orders for fentanyl and Zyprexa. Another resident’s hospice med profile was outdated and did not match the facility MAR/orders, with discrepancies in Zoloft and cyclobenzaprine. Staff stated the hospice binder should contain current hospice documentation and match facility orders for continuity of care.
A resident on hospice with stroke-related deficits, moderate cognitive impairment, and dependent ADL needs had thick, long toenails noted by the NP, but the facility did not notify hospice about the podiatry request. Surveyors observed the toenails needed trimming, the SW said the resident was not on the podiatry list, and the hospice RN confirmed there was no record of the facility contacting hospice about the issue.
The facility failed to keep hospice SN and CHHA notes in the records for two residents receiving hospice services. One resident had CHF and the other had Alzheimer’s dementia, and both had hospice care plans, but the hospice binder and medical records lacked the required visit notes. Staff interviews also showed confusion about who served as the hospice coordinator, with one LPN naming the DON and an RN naming the ADON.
A resident receiving hospice services had severe cognitive impairment, lower-extremity impairment, and pressure injuries, but the facility did not establish clear hospice collaboration and communication processes. The DON stated there was no single staff member responsible for reviewing hospice notes or coordinating with hospice, and the resident’s hospice visit notes were not available to direct care or licensed nursing staff.
Missing Hospice Election and Certification Documents
Penalty
Summary
The facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for a resident receiving hospice services, and failed to ensure that the resident’s hospice documents were present in the hospice binder. Resident #23 was a [AGE]-year-old female admitted to the facility on 04/01/26 with diagnoses including schizophrenia, malignant neoplasm of the right breast, secondary malignant neoplasm of axilla and upper limb lymph nodes, and mild intellectual disabilities. Her Significant Change MDS showed a BIMS score of 5, indicating severe cognitive impairment, and her comprehensive care plan showed hospice services were initiated on 06/15/26. The Physician Order Summary dated 07/16/26 showed she was admitted to [Hospice Company] for malignant neoplasm of the right breast with an order date of 06/12/26. Record review of the hospice binder for Resident #23 on 07/15/26 at 3:00 PM showed there were no forms under the tab for Form 3071 and Form 3074. During initial rounds on 07/13/26 at 10:45 AM, Resident #23 was observed visiting with a hospice employee in her room, and during interview on 07/15/26 at 10:55 AM she confirmed she had a visitor from hospice and stated she was pleased with services from the facility and hospice and received help when needed. During interview on 07/15/26 at 3:30 PM, the DON stated she would have to ask the hospice company why Forms 3071 and 3074 were not in the hospice binder because they are responsible for the binder; the DON then called the hospice company and they faxed the forms to her. The facility’s hospice policy stated that when a resident participates in hospice, a coordinated plan of care between the facility and hospice agency is developed and the resident’s care plan should be revised and updated with changes.
Missing and Outdated Hospice Plan of Care
Penalty
Summary
The facility did not ensure that hospice services met professional standards and principles for a resident receiving hospice care. The deficiency involved one resident, who was admitted to the facility with diagnoses including malignant neoplasm of connective and soft tissue of the right lower limb/hip, chronic ulcers of the right foot and lower leg, chronic pain, and pain in the right leg, and who was admitted to hospice with a primary hospice diagnosis of primary angiosarcoma of the right lower extremity. The resident’s comprehensive care plan included hospice-related interventions such as notifying hospice of changes in condition or medication changes and providing emotional support during decline. Surveyors interviewed multiple staff members about where the resident’s hospice care plan and hospice documentation were kept. A CNA stated hospice managed the resident’s wound and pain medications and said a care plan was located in the bathroom. An LPN stated the hospice care plan was in the PCC electronic record. The DON stated hospice notebooks were at the nurse’s station. However, when surveyors asked staff to locate the hospice binder, an LPN and an RN could not find it, and the RN stated hospice usually fills it out and brings it back to the nurse’s station, but it was not there at the time. Later, staff showed surveyors a binder containing only hospice contact information and no plan of care. The resident’s paper chart contained a hospice plan of care, but it had been printed that day and still reflected that the resident was living at home with home health services, which an MT acknowledged needed to be updated. The MT also stated hospice providers print their notes and include them in the paper chart, but she did not see evidence of those visit notes in the chart. The DON stated the facility gets hospice notes every time hospice visits and that floor nurses and unit managers are responsible for obtaining the notes and keeping the hospice care plan updated, but she also stated the resident’s binder was missing and described it as a fluke. The facility did not ensure collaboration and coordination with hospice for a complete plan of care for the resident receiving hospice services.
Hospice binders were incomplete and medication profiles did not match facility orders
Penalty
Summary
The facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for two residents receiving hospice services. For Resident #12, the hospice binder in the facility did not contain the most recent medication profile, the last two months of IDG meetings, or an updated recertification form. The binder also did not include orders for Fentanyl Transdermal Patch 12 mcg/hr every 72 hours or Zyprexa 7.5 mg at bedtime, even though those orders were present in the resident’s chart. The resident’s record showed diagnoses including dementia, anxiety, and depression, and the MDS indicated she was on hospice services with moderate cognitive impairment. During interview, the hospice RN stated the facility’s binder should contain supporting hospice documentation, including the face sheet, election form, code status, certification of terminal illness, plan of care, and medications. She said IDG meetings occurred every two weeks and the documentation should be updated the following week, but the updated information for Resident #12 had not been delivered to the facility. She stated the last IDG meetings on 06/12/26 and 06/26/26 had not been provided and that the recertification period beginning 06/18/26 and ending 08/16/26 should also have been in the facility chart. The LVN and DON stated the hospice binder should include required material such as recertification and IDG meetings, and the DON said hospice should correlate with facility nurses regarding medication changes. For Resident #27, the hospice binder contained a medication profile dated 03/30/26 that did not match the facility’s current orders. The hospice medication profile listed Zoloft 25 mg at bedtime and cyclobenzaprine 10 mg twice daily, but the facility order summary showed sertraline 50 mg at bedtime, cyclobenzaprine 10 mg twice daily, and an additional cyclobenzaprine 10 mg every 24 hours as needed for leg cramps. The ADON and DON stated the hospice medication profile should have matched the facility orders and that the hospice nurse should communicate with the facility nurse to ensure there were no new orders. The DON also stated the facility did not have a hospice policy.
Failure to Coordinate Hospice Communication for Podiatry Needs
Penalty
Summary
The facility failed to ensure hospice services were coordinated with the resident’s needs when Resident #2’s NP recommended podiatry evaluation for his long toenails, but the facility did not notify hospice of that request. Resident #2 was admitted with diagnoses including cerebral infarction due to thrombosis of the right middle cerebral artery and hemiplegia/hemiparesis affecting the left dominant side. His baseline care plan reflected that he was totally dependent on staff for ADLs, including dressing, footwear, personal hygiene, showering, and bed mobility. He also had moderate cognitive impairment on BIMS testing and was receiving hospice services. Record review showed the resident had left great toe eschar present on admission and later developed a left 2nd toe arterial ulcer. On 06/20/2026, the NP documented edema of the left foot, dry skin, insensate lower extremity, and an arterial ulcer with full thickness, and recommended routine in-house podiatry evaluation for management of thickened nails. However, the resident was not on the SW’s podiatry list at the time of survey, and the SW stated the NP or MD should have contacted her so the resident could be added for podiatry on the next visit. The SW also stated podiatry rounds occurred every two to three months. During observation, surveyors found the resident’s toenails on both feet were thick and needed trimming, and the resident stated he had been at the facility for two weeks and someone had cut only one toenail. The resident and family member reported the toenails had already been long. The hospice RN stated there were no records of the facility calling hospice about the long toenails before the survey date, and that the facility should have communicated the request so hospice records and the care plan reflected it. The facility policy stated it was the facility’s responsibility to meet the resident’s personal care and nursing needs in coordination with hospice and to communicate with hospice to ensure needs were addressed.
Missing Hospice Documentation and Unclear Hospice Coordinator
Penalty
Summary
The facility failed to provide the necessary care and services for two residents receiving hospice services by not ensuring that hospice skilled nurse visit notes and CHHA notes were available in the residents’ medical records. For one resident, the record showed admission to hospice for chronic systolic congestive heart failure on routine level of care, with a care plan reflecting hospice services, but the hospice binder and medical records did not contain the June 2026 skilled nurse hospice progress notes or CHHA notes. For the other resident, the record showed hospice services for Alzheimer’s dementia on routine level of care, with a care plan reflecting hospice involvement, but the hospice binder and medical records did not contain the May and June 2026 skilled nurse hospice progress notes or CHHA notes. The facility’s policies required communication between the facility and hospice provider to be documented and required designation of a facility interdisciplinary team member to coordinate with hospice representatives. During interviews, an LVN verified that the hospice documents should have been in the binder or medical record for communication and awareness of what to follow through for the residents. The LVN identified the DON as the hospice designee/coordinator, while an RN identified the ADON as the hospice coordinator, showing staff were not aware of a consistent hospice designee/coordinator.
Hospice notes were not available to facility staff and no staff member was designated to coordinate hospice care
Penalty
Summary
The facility did not ensure hospice collaboration and communication processes were established to maintain continuity of care between hospice and facility staff for one resident receiving hospice services. The facility policy stated that there should be a designated interdisciplinary team member responsible for coordinating care with hospice representatives and communicating with hospice staff, but the facility did not designate one person for that role. During interview, the DON stated there was no single staff member responsible for reviewing hospice notes; instead, floor nurses reviewed them and shared changes with managers, while managers updated care plans. The resident, R40, had severe cognitive impairment with a BIMS score of 0 out of 15, lower extremity impairments, dependence on staff for rolling in bed, and pressure injury risk with one stage 2 pressure injury and one unstageable pressure injury. The resident’s care plan indicated hospice services for cerebrovascular disease and referenced hospice care plan information in the chart. On survey review of the hospice binder and electronic medical record, the surveyor could not locate hospice nurse notes in either location. When additional documentation was requested, some hospice notes were later provided, but the print date on those notes was 6/3/26. The surveyor also found that R40’s hospice visit notes were not available to the facility’s direct care or licensed nursing staff.
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