Failure to Coordinate Care for Hospice Resident Results in Fall and Injury
Penalty
Summary
The facility failed to ensure proper coordination of care between its staff and hospice staff for a resident receiving hospice services, resulting in a significant incident. The resident, a male with advanced dementia, hemiplegia, a history of falls, and multiple comorbidities, required total assistance for transfers, specifically with a mechanical lift and two-person assistance as documented in the care plan and physician orders. However, the hospice care plan did not reflect this requirement, and hospice staff were not consistently included in care plan meetings or provided with updated facility care plans. On the day of the incident, a hospice CNA attempted to transfer the resident from a shower chair to the bed without using the mechanical lift and without assistance, despite being aware of the resident's need for such support. The CNA reported being unable to find the sling for the lift and, after informing a facility LVN, was told it was acceptable to proceed with a manual transfer. During this process, the resident fell, sustaining a laceration to the forehead and a cervical spine fracture, which required hospitalization and ICU care. The incident was not immediately investigated by facility administration, and there was a lack of communication regarding the event until hospice staff later reported the failure to use the mechanical lift. Interviews revealed that hospice staff were not routinely invited to facility care plan meetings, and there was no established process for sharing or reconciling care plans between the facility and hospice. The hospice CNA admitted to sometimes transferring the resident without assistance due to lack of available staff or equipment. Facility and hospice staff both acknowledged gaps in communication and coordination, with hospice staff relying on their own care plans, which did not include the mechanical lift requirement, and facility staff not ensuring hospice staff were aware of or following the facility's care plan interventions.
Removal Plan
- The alleged perpetrator will not be returning to the facility.
- Out of cycle QAPI including this plan was presented to the Medical Director by the facility administrator. The medical director did not request changes to the plan.
- The Nursing staff/ current hospice agencies CNAs were in-serviced by facility DON/ADON and Regional Compliance Nurse on how to find the level of assistance required for transfer and mechanical devices required in the kiosk.
- Mechanical lifts were tagged with bright colored sign stating, two people required to operate the lift. This was done by the Maintenance Director. This will give a second opportunity for staff to be reminded prior to using the equipment.
- Facility Charge Nurses were in-serviced by the facility DON on how to read the facility Kardex.
- Current hospice agencies CNAs/facility nursing staff providing services to residents at the facility were in-serviced by the facility DON on how to review the residents Kardex located in the kiosk with the Charge Nurse prior to providing direct care to the residents to ensure that the staff is aware of the number of people required for transfers and use of any mechanical lifts. This will be randomly monitored by DON/ADON/Admin. To prevent the recurrence of falls and injuries.
- The facility Social Worker will be sending reminder emails to contracted hospice agencies to attend the required mandatory care plan meetings at the facility as scheduled. To ensure the coordination of services. This will be randomly monitored by Admin/DON/ADON.
- 100% of residents' records were reviewed to ensure that the information reflected in the Kardex/Care plans for any residents requiring assistance with transfer to include any assistive devices. This was done by DON/ADON and the Regional Compliance Team.
- Facility staff and current hospice agencies were in-serviced by the DON/ADON and compliance nurse on Abuse and neglect. No facility staff member or contract hospice agency staff will be allowed to provide care until receiving the in-service mentioned above.
- Hospice CNAs must sign in upon arrival and review the Kardex with the charge nurse to ensure the plan of care and level of assistance are understood before providing care. Education is posted at the nurse's station.
- All hospice staff must report to charge nurse and review Kardex. All hospice staff must report to the charge nurse upon arrival and review the Kardex before providing care. They must sign off that they have reviewed and understood the Kardex.
- In-service training on identifying and reporting abuse, neglect, and exploitation for hospice staff.
- Training addressed recognizing signs of abuse, neglect, and exploitation and the importance of timely reporting.