Failure to Follow Physician Orders and Coordinate Hospice Care
Penalty
Summary
Two residents did not receive care and services in accordance with professional standards, their care plans, and physician orders. One resident was admitted with an infection of a left lower extremity amputation stump and had discharge orders to follow up with vascular surgery within 2–7 days. Despite wound care progress notes on multiple occasions recommending vascular surgery follow-up due to worsening wound condition, there was no documentation that the appointment was scheduled. The unit clerk was tasked with scheduling the appointment, but as of the date the resident was transferred to the hospital for increased redness and changes at the surgical site, the appointment had not been made. Another resident, admitted with chronic obstructive pulmonary disease and chronic congestive heart failure, was placed on hospice services. The facility failed to ensure the hospice plan of care was available and integrated into the resident’s comprehensive care plan. Staff interviews revealed that the hospice binder, which should have contained the hospice plan of care, was empty and not accessible at the nurse’s station. The facility-generated care plan did not incorporate the hospice plan, and there was no evidence of collaboration with hospice staff to address the resident’s end-of-life needs and interventions. The DON confirmed that the hospice plan of care was expected to be current and available, but this was not the case.