Failure to Coordinate Care for Hospice Resident Results in Fall and Injury
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.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
The facility failed to coordinate hospice services within the care plans for two residents receiving hospice. Both residents had severe cognitive impairment and extensive ADL needs, and their MDS assessments documented hospice care. Their care plans included general directions about ADL assistance, pain monitoring, and consulting with hospice or the physician, but omitted key hospice-specific details such as hospice contact information, visit schedules, services to be provided, and what supplies, equipment, and medications hospice would furnish. Clinical record review and interviews with an administrative nurse confirmed that there was no documented coordination between hospice and facility care plans, contrary to the facility’s hospice policy requiring an interdisciplinary plan integrating hospice and facility services.
A resident receiving hospice services, with diagnoses including leukemia, dementia, anxiety, and depression, did not have a Hospice Election form maintained in the facility’s records as required. SOM Appendix PP and the facility’s hospice services agreement required a designated interdisciplinary team member to obtain and keep specific hospice documents, including the hospice election form, for each hospice patient. Record review showed the form was missing, and the CRN acknowledged it was not on file and stated she did not believe it needed to be included in the hospice documentation kept at the facility.
A resident with multiple diagnoses, including diabetes and severe protein-calorie malnutrition, was receiving hospice services with a documented DNR status, but the facility failed to maintain required hospice documentation in the medical record. Review of the chart showed there was no current hospice plan of care and no current terminal diagnosis certification. When requested by the surveyor, the DON produced only an expired terminal certification and a facility-generated care plan, and the Administrator confirmed that a current hospice plan of care and terminal certification were not present in the record.
A resident with severe cognitive impairment and multiple diagnoses was admitted to hospice for end-of-life care related to senile degeneration of the brain, with a care plan calling for coordinated hospice services and communication. However, staff reported not seeing hospice aides provide services and only occasional visits by a nurse, and a review of the paper chart found no hospice admission paperwork, care plan, or visit notes. As a result, details about hospice services, scheduling, communication processes, and triggers for contacting hospice were not available in the facility’s records, and leadership later acknowledged this non-compliance.
A resident on hospice with Alzheimer’s disease, aphasia, and prior stroke pulled out a G-tube and was sent to the ER for replacement after an MD order and ambulance transport were arranged. Nursing staff notified the hospital ER and the resident’s representative, but did not notify the hospice agency, and the transfer form reflected no hospice contact. A hospice representative later confirmed they were not informed, while the DON stated nurses were expected to notify hospice of changes in condition or hospital transfers and that this requirement was outlined in the facility’s hospice coordination policy.
A hospice resident with metastatic lung cancer, previously documented as full code, returned from a hospital stay under hospice care, but the facility did not obtain or maintain required hospice documents, including a DNR POLST, hospice election form, and physician certification of terminal illness, as required by policy and the hospice agreement. When the resident was later found unresponsive but with vital signs, an RN contacted hospice and the family, but only a DNR election form without a physician signature could be produced, and it took time to arrive. The family began compressions and called 911, and EMS requested hospice documents and a DNR POLST that the facility could not provide, leading to the resident’s transfer to the hospital. Surveyors found that the absence of a DNR POLST and complete hospice paperwork caused confusion among staff and emergency personnel and placed hospice residents at risk for their advance directives not being honored.
Failure to Coordinate Hospice Services in Resident Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and maintain a coordinated hospice plan of care that integrated hospice services with facility services for two residents receiving hospice. For one resident with Alzheimer’s disease, CAD, and atrial fibrillation, the Significant Change MDS documented severely impaired cognition and extensive assistance needs for bed mobility and transfers, and indicated the resident was receiving hospice services. The resident’s care plan noted a terminal prognosis due to Alzheimer’s, directed staff to adjust ADL care, consult the physician for hospice care in the facility, and monitor and treat pain, but it did not include instructions on hospice services such as hospice staff visit schedules, supplies, medical equipment, or medications covered by hospice. The clinical record showed the resident had been admitted to hospice care months earlier, yet there was no documented evidence of coordination of care between hospice and the facility. For the second resident, diagnosed with PVD, DM, HTN, and atherosclerotic heart disease, the Significant Change MDS showed severe cognitive impairment with a BIMS score of two and dependence on staff for most ADLs, and documented that the resident received hospice services. The resident’s care plan recorded admission to hospice and directed staff to adjust ADL provision, encourage participation as desired, assess coping, respect wishes, and consult with the physician and hospice for continuing hospice care, as well as monitor for pain and notify the physician and hospice for breakthrough pain. However, the care plan lacked a hospice contact number, information on what supplies, equipment, and medications hospice would provide, and details on when hospice staff would be in the building and what care they would deliver. Observations and staff interviews confirmed these omissions. One resident was observed in bed receiving eye drops from a CMA, and during record review, the Administrative Nurse acknowledged that the facility care plan lacked specific information coordinating with the hospice care plan. For the second resident, the Administrative Nurse verified that the care plan did not contain information regarding hospice visits, phone numbers, or medical supplies provided by hospice, and stated that such information should be on the resident’s care plan. These findings were inconsistent with the facility’s Hospice Services policy, which required an interdisciplinary care plan integrating facility and hospice services, including coordination of services and supplies provided by the hospice provider.
Failure to Maintain Required Hospice Election Documentation
Penalty
Summary
The facility failed to maintain complete hospice records for a resident receiving hospice services, specifically by not having a Hospice Election form on file. SOM Appendix PP requires that when a LTC facility arranges hospice care under a written agreement, a designated interdisciplinary team member with a clinical background must obtain specific hospice documentation, including the hospice election form, physician certifications, plan of care, and related information. The facility’s Hospice Services Facility Agreement, dated 12/2/25, also documented that the facility would arrange hospice services and that the designated facility member would obtain hospice coordination of care information and physician certification, including but not limited to the Hospice Election Form. Resident #18 was admitted with multiple diagnoses including leukemia, dementia, anxiety, and depression and was receiving hospice services. A review of this resident’s medical record and hospice documentation showed that the Hospice Election form was not included in the records maintained at the facility. On 4/2/26 at 11:46 AM, the Clinical Registered Nurse (CRN) confirmed that Resident #18’s Hospice Election form was not on record at the facility prior to requesting a copy from the hospice company that morning. On 4/6/26 at 2:15 PM, the CRN further clarified via email that she did not believe the election form needed to be included in the hospice documentation kept at the facility level.
Missing Current Hospice Plan of Care and Terminal Certification
Penalty
Summary
Facility staff failed to ensure that required hospice documentation was complete and available in the medical record for a resident receiving hospice services. The resident had multiple diagnoses, including diabetes, severe protein-calorie malnutrition, and a need for assistance with personal care, and the hospice care plan revised on a specified date documented that the resident was on hospice and had a DNR code status. Record review showed there was no current hospice plan of care and no current terminal diagnosis certification in the resident’s chart, both of which are required to initiate and maintain hospice services. When the surveyor requested these documents, the DON later provided a terminal certification with a benefit period that had expired 23 days earlier and only a facility-generated care plan, and the Administrator acknowledged that there was no current terminal certification or hospice plan of care in the resident’s record. The absence of required hospice documents created the potential for delayed or incomplete care due to lack of access to the hospice plan of care and current terminal certification.
Failure to Maintain Accessible Hospice-Coordinated Plan of Care
Penalty
Summary
The deficiency involves the facility’s failure to have a hospice-coordinated plan of care readily available and integrated into the resident’s record for a hospice-enrolled resident. The resident, admitted after an acute hospital stay, had diagnoses including atrial fibrillation and chronic venous insufficiency, and a significant change MDS showed a BIMS score of 3/15, indicating severely impaired cognitive abilities for daily decision-making. The resident’s care plan, dated 2/4/26, documented admission to hospice services for end-of-life care related to senile degeneration of the brain, with a goal to receive uninterrupted supportive services. Interventions listed included coordinating all of the resident’s needs, communicating changes to hospice, and educating the resident, family, responsible party, and caregivers about changing needs and additional hospice services. Despite this, staff interviews and record review showed that hospice services and coordination were not clearly documented or accessible in the facility. A CNA reported never seeing a hospice aide provide services to the resident and only observing a male nurse visiting approximately twice per week. When interviewed, the DON stated that hospice admission paperwork, the care plan, and visit notes were likely in the resident’s paper chart, but a review of the paper charts revealed no hospice documents. As a result, information about what hospice services would be provided, when and how they would be provided, the communication process, and when or why facility staff should contact hospice was not available in the facility at the time of review. Hospice documents confirming the resident’s hospice admission for senile degeneration of the brain were only produced later, after being faxed to the facility, and the facility leadership acknowledged the non-compliance during the surveyor’s discussion.
Failure to Notify Hospice of Resident’s Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to coordinate care with a hospice agency by not notifying the hospice provider of a resident’s transfer to the hospital. The resident was an elderly female with Alzheimer’s disease, aphasia, stroke history, short- and long-term memory problems, and severely impaired cognitive skills. She had been admitted to hospice services for Alzheimer’s disease. According to progress notes, an LVN documented that the resident pulled out her G-tube, the MD was notified, and an order was obtained to send her to the ER for G-tube replacement. The LVN arranged ambulance transport, and another LVN documented that the resident was transported to a named hospital, was stable, and that report was given to the hospital ER and the resident’s representative was notified. Record review of the eINTERACT Transfer Form showed the hospice company was not contacted about the transfer. During interviews, a hospice representative stated the hospice company was not informed of the resident’s hospital transfer and that they expected the facility to communicate when the resident went to the hospital. The DON stated that all nurses knew hospice agencies were supposed to be notified when a hospice resident had a change in condition or was sent to the hospital, and that the nurse on duty was responsible for this communication. The DON also stated she was not aware that hospice had not been notified and that nurse managers normally checked that all necessary parties were notified, but this was not done. An LVN reported he had told the oncoming LVN to call hospice about the transfer and assumed it would be done. The facility’s policy on Coordination of Hospice Services required immediate contact and communication with hospice staff, the attending practitioner, and the family/resident representative regarding significant changes, clinical complications, or emergent situations, which was not followed in this case.
Failure to Maintain and Provide DNR POLST and Hospice Documentation
Penalty
Summary
The facility failed to ensure that a physician’s order for life-sustaining treatment (POLST) and required hospice documentation were obtained, maintained on-site, and made available to emergency personnel for a hospice resident with metastatic lung cancer. The resident was initially admitted as full code with a POLST indicating full resuscitation, later hospitalized for acute on chronic hypoxic respiratory failure, and then returned under hospice care. A hospice policy and hospice agreement required the facility to maintain the most recent care plan including advance directives, the hospice election form, physician certification of terminal illness, and other hospice orders. However, review of the hospice binder and medical record showed that the hospice election form, physician certification of terminal illness, and advanced directives including a DNR POLST reflecting the resident’s DNR status were missing. The DON confirmed that the hospice DNR election form alone was not an acceptable substitute in the state because it lacked a physician’s order. On the day of the incident, the RN found the hospice resident unresponsive but with vital signs during morning rounds and contacted hospice and the family. The RN reported that there was no DNR POLST in the hospice binder and hospice could only provide a DNR election form, which took time to be received and did not have a physician’s signature. During this period, the family panicked over the resident’s unresponsive state, began chest compressions, and another family member called 911. When emergency medical services arrived, they requested hospice documents and the DNR POLST, but the facility was unable to provide them, and the resident was transported to the hospital. Surveyors determined that the lack of a DNR POLST and other required hospice paperwork in the facility, contrary to facility policy and the hospice agreement, resulted in confusion among staff and emergency personnel and placed hospice residents at risk for advance directives not being honored at end of life.
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