Failure to Implement Hospice Medication Recommendation for Symptom Management
Penalty
Summary
The facility failed to address and implement a medication management recommendation made by the contracted hospice agency for a resident receiving hospice care. Specifically, the hospice nurse recommended Ativan 1mg to be administered orally or sublingually every two hours as needed for breakthrough agitation. Review of the resident's physician orders did not show that this medication was ordered or addressed by the facility. The resident involved had multiple complex diagnoses, including multiple sclerosis, COPD, dementia, and anxiety, and was admitted to hospice care for senile degeneration of the brain. Despite the hospice agency's documented recommendation for symptom management, there was no evidence in the clinical record that the facility acted on or implemented the suggested medication. This was confirmed by the Assistant Director of Nursing during staff interview.