Hospice Records Not Readily Available for Review
Penalty
Summary
The facility failed to ensure that hospice records were readily available for review, which impeded effective collaboration between the facility and the hospice provider. For one resident with diagnoses including vascular dementia, cerebral atherosclerosis, bone disorders, and hypertension, hospice services were arranged to include CNA visits three times per week, weekly nursing care, and monthly social services. Hospice staff were expected to provide care summaries to the facility after each visit. However, when surveyors requested hospice notes for this resident, only a sign-in log was found in the designated binder at the nurse's station, and no hospice care notes were immediately available. Staff interviews revealed confusion regarding the location of hospice records, with one RN believing the unit manager might have the notes, but they were not accessible at the time of request. The hospice notes were only provided later that day after being printed and forwarded by the hospice provider upon request. An LPN confirmed that the documents were not present in the facility and had to be obtained from hospice. Facility policy required designated staff to ensure communication and documentation with hospice providers, but this was not followed, resulting in the deficiency.