Failure to Obtain and Document Required Hospice Charting
Penalty
Summary
The facility failed to ensure that the designated interdisciplinary team member obtained the required information from the contracted hospice provider for a resident receiving hospice services. Specifically, for a resident with a diagnosis of cancer and cognitive impairment, there was no documented evidence that updated hospice nurse aide or registered nurse charting was obtained and included in the resident's clinical record or the hospice provider's clinical record. The last available hospice nurse aide charting was dated nearly a month prior, and the last registered nurse charting was also outdated. A significant change Minimum Data Set (MDS) assessment indicated that the resident was cognitively impaired and receiving hospice services for basal cell carcinoma of the left upper limb. The care plan and physician's orders confirmed the resident was to be treated by hospice for end-of-life services. Despite these orders, the required documentation from hospice staff was not present in the records as of the review date. An interview with the Director of Nursing confirmed that the hospice nurse aide and registered nurse charting was missing from both the resident's clinical record and the hospice provider's clinical record, and acknowledged that this documentation should have been present. This lack of documentation demonstrates the facility's failure to meet regulatory requirements for coordination and documentation of hospice care services.
Plan Of Correction
F 0849 Resident 25's updated hospice nurse aide and updated hospice Registered Nurse charting was immediately placed into the hospice provider's clinical record. Any resident receiving hospice services has the ability to be affected by this alleged deficient practice. A baseline audit of residents receiving hospice services has been completed to ensure updated hospice personnel charting is present and available in the hospice provider's clinical record. The Director of Nursing re-educated hospice providers regarding the importance of and the need for updated charting documentation to be timely placed into the resident's hospice provider's clinical chart consistently. The Director of Nursing/designee will audit residents receiving hospice services for the presence of timely documentation of hospice providers' charting in the resident's hospice provider's clinical chart weekly times three weeks and then monthly times two months and then reviewed by the Quality Assurance Performance Improvement Committee for results, areas of improvement and/or continuation of audits. Results of these audits will be reviewed in Quality Assurance and Performance Improvement times three months or until substantial compliance is noted.