Failure to Ensure Communication and Documentation with Hospice Provider
Penalty
Summary
Facility staff failed to provide evidence of communication between the hospice company and the facility for one resident who had been admitted to hospice care. The physician order documented the resident's admission to hospice, and a request was made for records of communication between the facility and the hospice provider. Documentation from the hospice company, including visit notes, was only faxed to the facility on a later date, despite hospice visits occurring earlier. When questioned, the director of clinical services explained that received hospice information is given to the medical records department and uploaded into the electronic medical record system, but could not specify the expected timeframe for this information to be available in the record. Further investigation revealed there was no hospice communication book on the unit, and while nursing staff reported verbal communication with hospice staff, there was no system in place to ensure this information was accessible to all staff, including physicians. Facility policy requires coordination and communication with hospice representatives and the attending physician, as well as the collection of specific hospice documentation. However, the facility was unable to demonstrate that these requirements were met for the resident in question.