Failure to Maintain Accessible and Complete Hospice Documentation
Penalty
Summary
The facility failed to ensure that hospice services provided to a resident met professional standards and principles, specifically regarding the accessibility and documentation of hospice care notes. According to facility policy and the hospice agreement, both the facility and hospice agency were required to maintain complete, accurate, and readily accessible clinical records for each resident receiving hospice services. However, for one resident receiving hospice care, the hospice communication binder and electronic medical record lacked documentation of hospice Certified Nurse Aide (CNA) visits and activities of daily living (ADL) care, as well as hospice nursing assessments. Only a single CNA note from a joint visit was present, and there was no verification of ongoing hospice CNA visits as outlined in the plan of care. The resident involved was over 65 years old, with multiple diagnoses including high blood pressure, psoriatic arthritis, depression, anxiety, dementia, a history of fractures, a stage 3 pressure ulcer, and cognitive impairment. The resident was dependent on staff for hygiene, bathing, transfers, and repositioning, and was receiving hospice services as documented in the minimum data set assessment. The hospice plan of care specified that a hospice CNA was to provide showers and other personal care twice a week, but the required documentation of these visits and care activities was missing from the records reviewed during the survey. Interviews with facility staff, including LPNs, CNAs, the Social Services Director, and the Assistant Director of Nursing, confirmed that hospice staff were expected to provide showers and ADL support to the resident. Staff reported that hospice CNAs checked in with facility nurses upon arrival, but also acknowledged that hospice CNA notes were not present in the facility's records and were being sought during the survey. The lack of accessible and complete documentation of hospice services constituted a failure to meet the standards required by facility policy and the hospice agreement.