Failure to Maintain Updated Hospice Documentation and Coordination
Penalty
Summary
The facility failed to collaborate and coordinate with hospice representatives to ensure the hospice care planning process was properly managed for a resident receiving hospice services. Specifically, the facility did not obtain the most recent updated hospice plan of care and hospice nursing visit notes for a female resident with a history of cerebrovascular disease, seizures, and dementia. The resident was moderately cognitively impaired and was receiving hospice care as indicated in her care plan and medical orders. However, the hospice binder at the facility only contained outdated documents, with the most recent RN visit note and hospice plan of care update both over a month old. Interviews with the Hospice Director of Nursing (DON), facility DON, and Administrator revealed that hospice documents were expected to be delivered to the facility every two weeks following the hospice interdisciplinary team (IDT) meeting. Due to the absence of the hospice Assistant Office Manager, the updated documents had not been delivered as required, and the responsible staff had not realized the lapse. The facility's contract with the hospice provider required the provision of the most recent hospice plan of care and clinical notes after each visit, but these were not present in the resident's records at the time of the survey.