Failure to Collaborate with Hospice on Pressure Ulcer Care
Penalty
Summary
The facility failed to collaborate with hospice regarding the care of a resident who developed a stage 2 pressure ulcer on the lower back. Hospice documentation indicated that the wound was first identified and treated by hospice staff, with specific wound care instructions documented. However, there were no corresponding physician orders or treatment records in the facility's documentation for the pressure ulcer during the same period. Interviews with facility staff, including an LVN and the DON, confirmed that the facility was not informed by hospice about the presence of the stage 2 pressure ulcer, and no treatment orders were received or implemented by the facility. The facility's policy required collaboration and regular communication between hospice and facility staff, including informing nursing staff of any changes recommended by hospice and including hospice notes in the facility's progress notes. Despite this policy, the facility was unaware of the pressure ulcer and did not provide or document any treatment for it. The deficiency was identified through record review and staff interviews, which revealed a lack of communication and documentation regarding the resident's wound care needs.