Failure to Coordinate Hospice Care and Maintain Required Documentation
Penalty
Summary
The facility failed to coordinate a plan of care with the hospice provider and ensure that required hospice documentation was present in the medical record for a resident receiving hospice care. The resident, who had Alzheimer's disease and end stage dementia, was admitted to hospice services, but the facility's electronic medical record lacked current hospice orders, a signed election form, a hospice plan of care, hospice physician orders, hospice physician notes, a hospice medication list, and hospice nursing notes. The most recent hospice documentation in the facility's record was several months old, despite ongoing hospice services. Interviews with facility and hospice staff revealed that hospice assessments and notes were maintained on hospice staff tablets and were supposed to be sent to the facility, but this did not occur as required. Facility nurses reported that hospice staff would have them sign their tablets after visits but did not provide verbal or written reports, and hospice documentation was not integrated into the facility's care plan. The Director of Nursing confirmed that there was no collaboration between the facility and hospice staff to update the care plan, and that the process for obtaining and coordinating hospice documentation was lacking. The administrator and Director of Nursing acknowledged that there was no established process to monitor and update hospice documentation or to ensure that hospice information was included in the facility's care plan. As a result, the resident's care plan did not reflect current hospice interventions or coordination between the facility and hospice provider, and essential hospice documentation was missing from the resident's medical record for an extended period.