Failure to Accurately Document Hospice Care in Resident Assessment
Penalty
Summary
The facility failed to ensure the accuracy of resident assessments for one of five residents reviewed. Specifically, a resident with diagnoses including diabetes, dementia, and a history of repeated falls was re-admitted to the facility and later admitted to hospice services per a physician order. However, review of the Minimum Data Set (MDS) assessments dated after the hospice admission showed that the resident's hospice care status was not accurately documented in Section O: Special Treatments, Procedures, and Programs. Both the MDS dated 12/14/24 and 3/16/25 failed to indicate that the resident was receiving hospice care, despite the active physician order for hospice services. During an interview, the Registered Nurse Assessment Coordinator confirmed that the facility did not complete an accurate assessment for the resident. Facility policy requires comprehensive and accurate assessments, including the completion of the MDS and documentation of all special treatments and services, but this was not followed in this case, resulting in an inaccurate record of the resident's care status.
Plan Of Correction
R71's MDS assessments were modified to reflect hospice care. MDS assessments for all residents on hospice were reviewed to ensure they indicated the residents were receiving hospice care. No other inaccuracies noted. NHA or designee will educate the MDS department on routine auditing of residents on hospice to ensure it is captured in their assessments. MDS Coordinator or designee will audit resident assessments for hospice care weekly x 4 weeks, then monthly x 2 months. Results will be reviewed at QAPI and revised as needed.