Failure to Coordinate Hospice Care and Documentation for Two Residents
Penalty
Summary
The facility failed to develop and implement a coordinated plan of care with hospice services for two residents who were admitted under hospice care, one with hypertensive heart disease and the other with vascular dementia. The facility did not invite or include hospice staff in the interdisciplinary team (IDT) meetings for either resident, and there was no documentation that hospice staff were informed of or attended these meetings. The IDT assessments and progress notes for both residents did not specify the hospice services being provided or the name of the hospice agency involved. Additionally, the facility did not ensure that hospice agency documentation, such as nurse progress notes, IDT notes, and plan of care updates, were available in the residents' facility medical records. For both residents, there were no hospice orders in the physician orders for the relevant months, and hospice care plan interventions were not transferred into the facility's care plans or physician orders. Staff interviews confirmed that hospice documentation was missing from the residents' records and that the process for sharing and integrating hospice information was not followed. Facility staff, including the MDS nurse, Social Service Director, and DON, acknowledged that hospice staff had not been invited to IDT meetings and that hospice documentation was not consistently incorporated into the residents' records. The hospice nurse also confirmed she had not been contacted or invited to participate in care conferences and was unaware of the facility's process for joint care planning. The facility's own policy emphasized the importance of joint care and communication between hospice and facility staff, which was not adhered to in these cases.