Failure to Complete Significant Change Assessment Upon Hospice Admission
Penalty
Summary
The facility failed to complete a significant change of condition assessment for one resident when the resident was admitted to hospice care. The resident, who had a history of paraplegia, chronic kidney disease, obstructive and reflux uropathy, adult failure to thrive, and was receiving palliative care, was observed to have hand contractures and required assistance with mobility. Despite a documented order for hospice care and a hospice consult, there was no evidence that a change of condition assessment was completed at the time of the transition to hospice services. Interviews with staff, including an LVN and the DON, confirmed that such an assessment was required by facility policy and should have been conducted immediately upon the resident's change in status. The absence of this assessment meant that the resident's change in condition was not reported to direct care staff, the RN, attending physician, family, interdisciplinary team members, or nursing leadership. Facility policy and job descriptions reviewed indicated that prompt notification and comprehensive assessment are required when a significant change in a resident's condition occurs. The failure to complete and communicate the assessment had the potential to result in unmet care needs for the resident.