Failure to Maintain and Document Hospice Coordination for Resident
Penalty
Summary
The facility failed to ensure proper coordination of care between the hospice team and facility staff for a resident with a terminal diagnosis of dementia who was admitted under hospice services. Despite an agreement and facility policy requiring communication and documentation of hospice care, the resident's clinical records and dedicated hospice binder lacked essential hospice documents, including the hospice plan of care (POC), visit schedules, and visit notes. The only hospice-related document present was the consent for hospice services, and the hospice sign-in and visit log were blank. Licensed nurses and the DON confirmed that there was no documentation of hospice visits or communication, and staff were unaware of the hospice staff's schedule or the disciplines assigned to the resident. Interviews with nursing staff and leadership revealed a lack of understanding and implementation of the process for coordinating care with the hospice agency. The DON acknowledged that the absence of hospice documentation in the resident's records meant that staff might not be aware of the resident's current care needs or any changes in their condition. The facility's own policy and the service agreement with the hospice agency required the maintenance of medical records, including progress and clinical notes describing all inpatient services, but these were not present for the resident receiving hospice care.