Failure to Coordinate and Document Hospice Services for Resident
Penalty
Summary
The facility failed to establish and maintain effective communication, collaboration, and coordination of care between the facility and the hospice provider for a resident receiving hospice services. Review of the facility's policy indicated that a designated staff member should coordinate care with hospice and that a care plan should be established to identify specific responsibilities. However, the resident's care plan did not include any focus, goals, interventions, or coordination related to hospice care. Interviews with staff revealed that nursing assistants were not informed the resident was on hospice, and the care manager was unaware of the required care plan elements for hospice residents. The care manager also failed to document conversations with hospice or include hospice contact information in the resident's profile. Further interviews with the Director of Nursing and Regional Nurse Consultant confirmed that the care plan lacked required hospice information, such as the hospice provider's name, contact details, and delineation of responsibilities between hospice and facility staff. The resident in question had diagnoses of emphysema and COPD with exacerbation, required partial assistance with activities of daily living, and had intact cognition. The lack of a coordinated care plan and communication system placed the resident at risk for not receiving necessary care and services as required by facility policy and regulatory standards.