Failure to Ensure Communication and Documentation of Hospice Services
Penalty
Summary
The facility failed to ensure that hospice services provided to two residents met professional standards and principles, specifically in the areas of communication and documentation between the facility and the hospice provider. The facility did not establish a consistent process for documenting communication with the hospice agency, nor did it ensure that hospice staff notes were easily accessible to facility staff. For both residents, there was no documentation in the electronic medical record of hospice provider visits over a period of several weeks, despite care plans indicating regular hospice nurse and CNA visits. One resident, under the age of 65 with advanced Huntington's disease and other significant diagnoses, was noted to have severe cognitive impairment and was receiving hospice services. The resident's representative expressed frustration with the lack of communication regarding the replacement of a broken Broda chair, which had been unresolved for several weeks. Although a hospice nurse was observed interacting with the resident's representative, there was no documentation of this visit in the facility's records. Additionally, there was no documentation confirming the delivery of a new chair, despite care plan interventions and interdisciplinary notes indicating hospice was to provide one. Another resident, over the age of 65 with multiple chronic conditions and cognitive impairment, was also receiving hospice services. The care plan called for regular hospice nurse and CNA visits, but the facility's records did not contain documentation of any hospice provider visits for over a month. Staff interviews revealed inconsistent practices regarding hospice staff check-ins and documentation, with hospice staff sometimes unable to access the designated binder for notes and not consistently leaving progress notes. Facility leadership acknowledged that hospice notes were sent every two weeks but were not always available in the residents' electronic medical records, further contributing to the lack of accessible and consistent documentation.