Failure to Coordinate and Document Hospice Services for Residents
Penalty
Summary
The facility failed to ensure proper communication and coordination between the hospice provider and facility staff for two residents receiving hospice services. For one resident with multiple diagnoses including epilepsy, bipolar disorder, depression, hypertension, atrial fibrillation, and morbid obesity, the care plan documented enrollment in hospice but lacked essential information such as the hospice contact number, details on supplies, equipment, and medications provided by hospice, as well as the schedule and nature of hospice staff visits. The care plan only directed staff to document advanced directive reviews and maintain these directives, without specifying the scope of hospice involvement or coordination. Another resident, diagnosed with hypertension, trigeminal neuralgia, and major depressive disorder, also experienced a lack of detailed hospice care planning. The care plan indicated hospice enrollment and directed staff to honor advance directives, but did not provide instructions regarding the services hospice would supply, the services the facility would continue to provide, or the process for communication and documentation between the facility and hospice provider. There were no directions for staff on when to notify hospice of significant changes in the resident's status, clinical complications, transfers, or death, nor was there information on the frequency or timing of hospice visits. Interviews with administrative nursing staff confirmed awareness of these omissions, acknowledging that care plans were incomplete and lacked required information about hospice services. The facility's own hospice policy required coordinated care plans and clear communication with hospice providers, but this was not reflected in the care plans reviewed for the two residents, placing them at risk of not receiving needed care.