Failure to Notify Hospice of Significant Change in Resident Condition
Penalty
Summary
The facility failed to notify hospice services following a significant change in condition for a resident who was admitted with hepatic encephalopathy, dementia, anxiety, and was under hospice care for a terminal cardiac diagnosis. On the morning in question, the resident was observed lying in bed with visible soiling, spilled food, and dirty clothing, indicating a lack of assistance with eating and personal care. Staff interviews revealed that the resident had been combative during breakfast, resulting in a mess, and that staff were instructed to step away and return later when the resident was calmer. However, there was no documentation in the clinical record to support the occurrence of a combative episode or the interventions taken. Further review showed that hospice was not informed of the resident's change in condition, despite contractual and policy requirements mandating immediate notification of hospice for significant changes in a hospice patient's status. The hospice RN confirmed that they had not been contacted and emphasized the importance of such communication for collaborative care. The facility was unable to provide requested documentation or surveillance footage to support staff accounts or demonstrate appropriate follow-up, highlighting a failure to ensure proper coordination with hospice services and adherence to care policies.