Failure to Coordinate and Document Hospice Services for Two Residents
Penalty
Summary
The facility failed to ensure proper coordination of care between facility staff and hospice providers for two residents who were receiving hospice services. For one resident with a history of cerebral infarction and intracerebral hemorrhage, the facility did not maintain complete hospice nursing visitation calendars or documentation for June and July. The hospice binder lacked required sign-in sheets and care notes from registered nurses, licensed vocational nurses, and nurse aides, as stipulated by the hospice agreement. The only available documentation was a social worker's signature for one date, and the facility's designated staff confirmed that without proper documentation, it was unclear if visits occurred or what care was provided. For another resident with Alzheimer's disease and hemiplegia, the facility was unable to verify that scheduled hospice visits by registered nurses and licensed vocational nurses took place in June and July. The hospice visiting calendar and sign-in forms were incomplete, and there were no corresponding nursing notes. Facility staff, including licensed vocational nurses, reported not seeing hospice nurses visit the resident, and the medical records director could not locate any hospice notes or sign-in information for the scheduled visits. The director of nursing acknowledged that the facility should have ensured collaborative communication and documentation between facility and hospice staff, as required by policy and the hospice agreement. Facility policy required coordination of care, communication, and documentation between facility and hospice staff to ensure residents' needs were met. The policy also designated specific staff to coordinate hospice care and required that hospice staff sign in and provide visit notes. The lack of documentation and incomplete records for both residents indicated that the facility did not follow its own policies or the hospice agreement, resulting in a failure to ensure that hospice care and services were provided as ordered by the physician.