Failure to Maintain Hospice Documentation
Penalty
Summary
The facility failed to maintain required hospice documentation for one resident who was receiving hospice care. Record review showed that the resident had multiple diagnoses, including adult failure to thrive, malnutrition, muscle weakness, Parkinson's disease, atrial fibrillation, and chronic kidney disease, and had been admitted to hospice care. Despite this, there was no documentation from hospice visits in the hospice communication binder, electronic medical record, or paper medical record for this resident. Staff interviews confirmed the absence of completed hospice communication forms and noted difficulties in obtaining the necessary binder from hospice. The facility's policy required maintaining hospice communication, but this was not followed for the resident in question.