Failure to Maintain Required Hospice Documentation in Clinical Record
Penalty
Summary
The facility failed to ensure that hospice documentation was properly maintained in the clinical record for one resident. Review of the hospice contract and facility policy indicated that coordination of care between facility staff and the hospice interdisciplinary team was required, and that hospice documentation should be incorporated into the facility's medical record. For the resident in question, who was admitted with diagnoses including interstitial pulmonary disease, chronic respiratory failure with hypoxia, pulmonary hypertension, and diabetes, there was a physician's order to admit the resident to hospice services. The clinical record included a hospice plan of care and a nurse's visit assessment, but lacked further evidence of ongoing collaboration or communication from hospice, such as communication sheets or detailed documentation of hospice services and service dates. During staff interviews, the DON confirmed that there was no additional hospice communication documentation in the resident's record beyond the initial nurse's assessment, and also confirmed that the physician's order for hospice services was not obtained at the time of admission. This lack of required documentation and timely physician order constituted a failure to comply with both the facility's policy and state regulations regarding hospice care coordination and record-keeping.