Failure to Maintain Communication and Documentation with Hospice Agency
Penalty
Summary
The facility failed to maintain communication with the hospice agency providing care to a resident who had been admitted with diagnoses including metabolic encephalopathy, incomplete paraplegia, and malignant neoplasm of the brain. The resident was admitted to hospice care for glioblastoma, and facility policy required that hospice nurse progress notes be placed in the resident's hospice binder after each visit. However, upon review, only one hospice nurse progress note was found in the binder, despite the expectation of weekly visits and corresponding documentation. Both the RN and the DON confirmed that these notes were essential for facility staff to stay informed about the resident's care and any changes in condition or physician orders. The DON stated that the Interdisciplinary Team (IDT) reviewed hospice patient care weekly, using the hospice nurse progress notes as a reference during meetings. The absence of these notes in the binder was not identified during these reviews, resulting in a lack of updated information regarding the resident's care from the hospice agency. The facility's own policy documented that the IDT was responsible for ensuring communication between the facility and hospice, but this process was not followed as required.