Failure to Coordinate and Document Hospice Services
Penalty
Summary
The facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for a resident receiving hospice services. Specifically, there was no evidence in the resident's comprehensive care plan that hospice services were being provided, despite the resident being admitted to hospice care. The clinical records lacked required hospice documentation, including the certificate of terminal illness, hospice election form, and documentation of communication between the facility and the hospice provider. The resident in question had severe cognitive impairment and multiple diagnoses, including Alzheimer's disease, kidney disease, and a urinary tract infection. Interviews and record reviews revealed that communication between hospice staff and facility staff was conducted verbally, and required communication forms were not being completed as per facility policy. The Director of Nursing acknowledged that the necessary documentation was missing and that it was her responsibility to ensure these documents were present. Facility policy required collaboration with hospice representatives, documentation of communication, and maintenance of specific hospice-related forms, none of which were found in the resident's records.