Failure to Maintain Hospice Documentation in Medical Records
Penalty
Summary
The facility failed to ensure that hospice records and communication were consistently included in the medical records for two residents receiving hospice services. For one resident with a history of stroke, cognitive communication deficit, hemiplegia, and a pressure ulcer, there was no documentation in the medical record of hospice communication, progress notes, or records of hospice visits and care provided. The hospice folder for this resident contained only general information and a care plan, but lacked visit documentation. The Assistant Director of Nursing confirmed that only social work staff could access hospice information through a portal, and other staff did not have access. For another resident with multiple diagnoses including spina bifida, heart failure, diabetes, and a stage 4 pressure ulcer, hospice services were reported by the resident and staff, but hospice notes and visit documentation were not found in the electronic medical record or in the hospice chart at the nurses' station. When a binder with hospice documents was eventually provided, it contained notes that were all printed on the same day, rather than being integrated into the ongoing medical record. The resident had also expressed concerns to hospice about the care received, specifically regarding ileostomy and wound care.