Failure to Maintain Hospice Documentation and Coordination
Penalty
Summary
The facility failed to ensure that a resident receiving hospice services had all necessary documentation and coordination in place. Specifically, the hospice visit calendar and the physician certification of terminal illness were not available in the resident's medical record. Multiple staff members, including LVNs, were unable to confirm the schedule of hospice visits or the identity of the hospice coordinator. The hospice binder did not contain the required calendar for scheduled visits, and staff were unsure about the frequency of hospice visits for the resident. Additionally, there was confusion among staff regarding who was designated as the hospice coordinator, with different staff members identifying either the QA Nurse or the social service department. Interviews with staff revealed a lack of awareness about hospice visit documentation and the process for communicating with the hospice provider. One LVN was unaware of whether hospice had visited regarding a specific equipment request and had to rely on a sign-in sheet for confirmation. Another LVN was unable to provide the physician's certification for hospice benefits when asked. The Director of Nursing later confirmed that the social worker was the hospice coordinator and acknowledged the findings related to missing documentation and unclear staff roles.