Failure to Update Clinical Records After Hospice Discharge
Penalty
Summary
The facility failed to maintain accurate and complete clinical records for a resident who was discharged from hospice services. Despite the resident's discharge from hospice, the medical record, including physician orders and the care plan, continued to reflect active hospice services. This included orders to call hospice for certain conditions and documentation indicating the resident was still under hospice care, even after official discharge notices and cancellation forms were present in the record. The resident in question had multiple complex medical diagnoses, including atherosclerotic heart disease, peripheral vascular disease, chronic venous hypertension with ulcer, chronic kidney disease, and hemiplegia. The resident was dependent on staff for all activities of daily living and had a history of behavioral symptoms and incontinence. Interviews with staff, including LVNs, CNAs, the DON, and the MDS Coordinator, confirmed that the resident was no longer receiving hospice services, and that the clinical record should have been updated to reflect this change. However, the orders and care plan remained unchanged, inaccurately indicating ongoing hospice involvement. Staff interviews revealed that responsibility for updating the clinical record was shared among nursing staff, with the MDS Coordinator and nurse managers having access to make necessary changes. The DON and Administrator acknowledged that the inaccuracy in the clinical record could lead to errors in care and treatment, as staff might follow outdated orders. The facility's policy required maintaining complete and accurate electronic clinical records, but this was not followed in this instance, resulting in the deficiency.