Failure to Maintain Accessible and Complete Hospice Documentation
Penalty
Summary
The facility failed to maintain complete, accurate, and accessible medical records for a resident receiving hospice services. Specifically, the resident was enrolled in hospice care, with a plan of care indicating that a hospice nurse and home health aide were to visit multiple times per week. However, a review of the resident's electronic health record (EHR) revealed no documentation of hospice nurse visits after a certain date, and the binder maintained for hospice documentation contained no records of visits by either the hospice nurse or home health aide. Multiple staff interviews confirmed that hospice staff documented in their own system, to which facility staff had no access, and that there was no consistent process for ensuring hospice visit notes were received or uploaded into the facility's EHR. Staff members, including RNs and the Director of Nursing Services, acknowledged that communication with hospice staff occurred verbally or by phone, but written documentation of hospice visits and care was not available in the facility's records. The hospice nurse and home health aide documented their visits and care activities in the hospice agency's system, but these records were not routinely shared with or accessible to facility staff. As a result, the facility did not have the required hospice documentation in the resident's medical record, as required by professional standards and regulations.