Failure to Maintain Required Hospice Documentation and Communication
Penalty
Summary
The facility failed to ensure that the required hospice communication process and documentation were followed for one resident receiving hospice services. According to the contract between the facility and the hospice provider, both parties are responsible for maintaining and sharing pertinent medical records and communication notes, with documentation to be included in the resident's medical record. However, upon review, the surveyor found that hospice progress notes and documentation were not present in the resident's medical record or hospice binder, and staff were unclear about the process for obtaining and maintaining these records. The resident in question had multiple diagnoses, including cerebrovascular disease, vascular dementia, schizoaffective disorder, and mild cognitive impairment, and was assessed as needing total assistance for all activities of daily living. The resident had been admitted to hospice care, but there was no evidence of hospice progress notes or communication in the medical record for several months. Staff interviews revealed inconsistent practices and a lack of clarity regarding who was responsible for collecting and filing hospice documentation, with some staff unaware of where hospice notes should be kept or how to access them. Further interviews with nursing, social work, and medical records staff indicated that hospice documentation was not routinely provided or collected, and that communication between the facility and hospice was often verbal and not consistently documented. The director of nursing and other staff acknowledged that documentation of hospice visits was not always completed unless there were changes or concerns, and that hospice notes were not always made available to the facility. As a result, the required hospice documentation and communication were not maintained in the resident's medical record as stipulated by the facility's contract with the hospice provider.