Failure to Maintain Hospice Documentation and Communication
Penalty
Summary
The facility failed to maintain proper communication and documentation of hospice services for one resident who was admitted to hospice care. The resident, who had multiple diagnoses including psychotic disorder, dementia, malnutrition, and Parkinson's disease, was cognitively impaired and dependent on staff for mobility and eating. Although there was an order for hospice admission, the facility's records only included hospice documentation up to March 2025, with no evidence of notes or documentation for April or May 2025. The hospice binder at the nursing station contained only calendars with visit notations and lacked details about the visits, care provided, or staff involved. Comprehensive assessments and physician orders were present, but there was no documentation from the previous year or recent months. Staff interviews revealed confusion about the location and maintenance of hospice records. The LPN was unsure if updated records were maintained, the liaison could not locate current hospice documentation in the electronic medical record, and the DON confirmed that records were missing and only in the process of being scanned. The Director of Social Services provided additional documents, but the most recent were still from March 2025. The hospice RN confirmed that hospice sent weekly bundles of notes to the facility and tracked their delivery, denying any delay on their part. Facility policy required coordination of care for hospice patients, but the necessary documentation was not maintained as required.