Failure to Coordinate Hospice Services and Ensure Continuity of Care
Penalty
Summary
The facility failed to coordinate care and services with hospice for a resident who had been admitted with multiple diagnoses, including severe dementia, malnutrition, and a history of falls. The resident was under palliative care and later enrolled in hospice, but the hospice care plan was incomplete, listing only assistance with feeding and lacking other necessary interventions. Documentation showed that the resident developed a pressure injury, but there was no evidence that hospice was notified of this change in condition, nor was there documentation of hospice involvement in the resident's ongoing care. Multiple assessments by facility staff and wound care practitioners identified and tracked the progression of the resident's pressure injury, including changes in wound stage and size. Despite these findings, hospice staff were not informed, and their own documentation failed to reflect the presence of the wound. Communication between facility staff and hospice was minimal or absent, with nurses reporting unsuccessful attempts to contact hospice and no updates or care coordination occurring. Hospice staff also did not communicate with facility staff or the resident's family, and their assessments did not accurately reflect the resident's condition. Interviews with facility staff, hospice staff, and the resident's family confirmed a lack of communication and coordination. There was no communication binder or process in place for sharing updates, and hospice staff did not follow established protocols for documenting visits or care provided. The facility's policy and the hospice contract both required collaboration and communication, but these were not followed, resulting in a lack of continuity of care for the resident.