Incomplete Documentation and Notification for Hospice Resident
Penalty
Summary
Facility staff failed to maintain complete and accurately documented medical records for a resident receiving Hospice services. The resident's medical record showed an instance of low blood pressure with no documentation that the resident's representative or Hospice provider was notified, as required by the facility's contract. Additionally, when the resident expired, the progress note did not clearly indicate whether the family was present at the time of death or arrived afterward, nor did it include an assessment supporting the determination of death. There was also no documentation of when, if, or how the Hospice provider was notified of the resident's death. These documentation gaps were confirmed by the Administrator and Director of Nursing.