Failure to Document and Communicate Hospice Services
Penalty
Summary
The facility failed to ensure that hospice services for a newly admitted female resident with diagnoses including anxiety, chronic pain, insomnia, and depression met professional standards and principles. Specifically, the resident's hospice care was not included in her interdisciplinary care plan, and there were no hospice licensed nursing visit notes present in either her hospice binder or medical record. Facility staff nurses were unaware that hospice documentation was required as part of the resident's medical record, and communication between the facility and the hospice provider was limited to verbal reports without proper documentation. Record reviews confirmed the absence of hospice nursing notes in both the hospice binder and the resident's medical record, and interviews with staff revealed a lack of awareness regarding the need for this documentation. The only documentation present in the hospice binder was contact information for the hospice and CNA sign-in sheets, with no licensed nurse visit notes available until after the issue was identified. The DON acknowledged that not having hospice notes in the medical record affected communication regarding the resident's care.