Failure to Maintain Accessible Hospice Documentation for Two Residents
Penalty
Summary
The facility failed to ensure that relevant hospice documentation was accessible for two residents who were receiving hospice services. For one resident, the nurse was unable to locate the comprehensive assessment, consent for hospice benefits, or the hospice comprehensive plan of care in the designated Hospice Notebook. The unit manager and social worker were also initially unaware of the location of these documents, and it was later revealed that the administrator had them. The documents showed that the resident had been admitted to hospice, but there was a possible lapse in service as indicated by the dates on the comprehensive assessment benefit period. The resident had multiple diagnoses, including atrial fibrillation, heart failure, diabetes, lymphedema, venous insufficiency, dementia, and acute respiratory failure, and required extensive assistance with daily activities. For the second resident, the hospice comprehensive assessment was not included in the electronic health record until a later date, despite the resident being admitted to hospice care earlier. This resident also had significant medical conditions, including acute cystitis, dysphagia, severe malnutrition, pressure ulcer, vascular dementia, aphasia, and major depression, and required maximal assistance for most activities of daily living. The Director of Nursing confirmed that the hospice documentation should have been accessible in the residents' records but was unable to explain why it was missing. The lack of accessible hospice documentation resulted in a lack of coordination of comprehensive services and care for both residents.