Failure to Ensure Communication and Collaboration with Hospice Providers
Penalty
Summary
The facility failed to ensure effective communication and collaboration with hospice providers for two residents receiving hospice services. For one resident with diagnoses including dementia, dysphagia, and aphasia, there was a lack of clarity regarding her hospice status. Although her medical record and care plan indicated she was to receive hospice services, her legal representative and social services staff confirmed she had been discharged from hospice, yet an active hospice order remained in her record. Nursing and administrative staff were unaware of the discharge, and there was confusion about the location and use of the hospice communication book, with no clear documentation or notification process in place. For another resident with multiple diagnoses such as malnutrition, epilepsy, and cognitive deficits, the facility's hospice communication binder did not contain up-to-date documentation of visits by hospice CNAs or nurses, with the last entry being from a social worker. Staff interviews revealed that hospice aides and nurses were expected to document their visits in the binder, but this was not consistently done. The hospice provider was only made aware of the missing documentation after being contacted by the facility, and there was a lack of evidence showing regular collaboration or communication between the hospice team and facility staff regarding the resident's care. The facility's own policy required ongoing interdisciplinary assessment and individualized care planning for residents receiving hospice or palliative care, including thorough documentation and communication with hospice providers. However, the observed practices did not align with these requirements, resulting in a breakdown of communication and collaboration for both residents, as evidenced by missing documentation, unclear discharge processes, and staff uncertainty about hospice involvement.