Failure to Coordinate Hospice Services Resulting in Untreated Pressure Ulcers and Uncontrolled Pain
Penalty
Summary
The facility failed to establish and implement an effective communication process with the hospice provider to ensure that a resident's needs were addressed and met. Upon admission to hospice services, the resident had multiple pressure ulcers and was experiencing uncontrollable pain, but there was no clear process or designated staff member responsible for coordinating care with hospice. The facility's care plan did not include hospice-related interventions at the time of hospice admission, and staff were unclear about their responsibilities regarding wound care and pain management, leading to confusion and lack of appropriate care. Observations and interviews revealed that the resident's pressure ulcers went untreated for approximately six weeks, and pain was not adequately managed, which limited staff's ability to perform activities of daily living. Nursing staff did not consistently assess or document the resident's wounds, and some believed that hospice or the wound care team was responsible for wound care, while others thought the facility was not responsible. Communication between facility staff and hospice was minimal, with neither party reaching out to the other regarding the resident's worsening condition or pain control issues. The hospice plan of care indicated that facility staff were responsible for wound care, but this was not communicated or understood by the facility staff. Interviews with facility leadership and hospice staff confirmed a lack of coordination and communication. The DON and nurse manager were unaware of the specific responsibilities outlined in the hospice care plan, and the medical director had not been informed of any concerns. The resident's family reported that the resident was in significant pain and not being repositioned, and that communication from the facility was lacking. The facility's own policy required a designated interdisciplinary team member to coordinate with hospice, but this was not in place at the time of the deficiency.