Failure to Maintain Hospice Nurse Visit Documentation
Penalty
Summary
The facility failed to maintain a system to ensure that a hospice resident's clinical binder contained required documentation of hospice nurse visit notes. Specifically, a review of a resident's clinical record and hospice binder showed that, although the resident was admitted to hospice care and had an active certification period, there were no hospice nurse visit notes or progress notes present in the binder. This was confirmed through interviews with the hospice liaison, an LPN, the hospice nurse, and the Director of Nursing, all of whom acknowledged the absence of the required documentation in the resident's hospice binder. The facility's policy requires that hospice services be provided or arranged to protect residents' rights, including maintaining appropriate documentation. Despite this policy, the hospice nurse confirmed that weekly assessment documentation had not been placed in the resident's binder, and other staff confirmed that hospice progress notes should have been updated and kept in the binder. This deficiency had the potential to affect any resident receiving hospice services in the facility.