Failure to Maintain Required Hospice Documentation for Residents
Penalty
Summary
Facility staff failed to provide necessary hospice documentation for two residents who were receiving hospice care. For one resident with severe cognitive impairment and multiple pressure ulcers, hospice nurses' notes and wound care measurements were not found in the medical record. Despite requests from surveyors and statements from both facility staff and the hospice nurse that such documentation should be available or could be provided, the records remained incomplete. The hospice agreement between the facility and the hospice provider required maintenance and retention of complete medical records, including current clinical findings, but these were not present in the resident's binder or electronic record. For another resident with late-stage Alzheimer's disease and other significant health issues, hospice nurses' notes and the comprehensive care plan were also missing from the electronic clinical record. The resident had been admitted, discharged, and readmitted to hospice services, and required substantial assistance with daily activities. Interviews with the administrator and hospice nurse confirmed that the required documentation was not in the resident's binder, and the hospice nurse indicated that notes were kept in their own system and only faxed to the facility upon request. In both cases, the facility did not maintain complete and appropriate medical records as stipulated in the hospice agreement. The lack of hospice nurses' notes and other required documentation was confirmed through observation, staff interviews, clinical record review, and facility document review. These deficiencies were communicated to facility leadership during surveyor interviews and meetings, but no additional information or documentation was provided prior to the survey exit.