Failure to Maintain and Update Hospice Documentation and Coordination
Penalty
Summary
The facility failed to properly collaborate with hospice representatives and coordinate the hospice care planning process for residents receiving hospice services. For three residents reviewed, the facility did not maintain or update hospice binders with essential documentation such as the most recent plan of care, hospice election forms, medication lists, and physician recertifications. In one case, a resident with diagnoses including malnutrition, anxiety, and COPD had a hospice binder missing updated care plans, medication lists, and IDG meeting notes, with the last recertification and documentation being outdated. Interviews with hospice staff confirmed that documentation should be updated at least weekly after IDG meetings, but this was not consistently done. Another resident, who was legally blind and had diagnoses including prostate cancer and depression, had a hospice binder lacking an IDG comprehensive assessment and an up-to-date medication review. The most recent plan of care was outdated, and the facility's electronic medical record had not been updated with hospice documents for several months. The hospice RN acknowledged responsibility for updating the binder but noted frequent changes and admitted the binder was not current, which could result in the facility not having accurate information. A third resident with end-stage heart failure and renal disease also had a hospice binder missing updated plans of care, medication lists, and notes from nurses, aides, and social workers since the last IDG meeting. Facility staff, including the DON, Social Services, and Medical Records, were unclear about who was responsible for maintaining the hospice binders and how often updates should occur. The facility had recently experienced a gap in medical records staffing, leading to a lack of a system to ensure hospice documentation was consistently updated and available for continuity of care.