Failure to Coordinate and Monitor Hospice Services
Penalty
Summary
The facility failed to ensure coordinated hospice service visits for a resident who was admitted with multiple diagnoses, including dementia, acute respiratory failure, high blood pressure, and Alzheimer's disease, and who was enrolled in hospice services. Record review showed significant gaps in hospice nurse and aide visits, with only three nurse visits documented over a one-month period and inconsistent aide visits, including a complete absence of aide visits for one month. The hospice visit schedule provided by the facility was unclear, lacking information on the discipline of staff making the visits, and was difficult to read. Interviews with facility staff revealed a lack of clarity regarding who was responsible for monitoring hospice staff visits. The social worker was unable to identify who ensured hospice services were provided as scheduled and did not follow up with this information. The DON acknowledged that a facility-initiated care plan for hospice services should have been in place but was not. Review of the facility's hospice policy confirmed the responsibility to coordinate care and maintain updated care plans, which was not met in this case.