Failure to Coordinate and Document Hospice Services
Penalty
Summary
The facility failed to ensure proper coordination and documentation of hospice services for one resident with a terminal diagnosis of cerebrovascular disease and severe cognitive impairment. The resident had physician orders for hospice care, including skilled nurse visits once a week and hospice aide visits twice a week. However, review of the hospice binder and sign-in sheets revealed that the last documented hospice aide visit was nearly two months prior, and the last skilled nurse visit was several weeks prior to the review. There was no evidence in the hospice binder to confirm that the required visits were being completed as ordered. Interviews with facility nursing staff, including an RN and an LVN, revealed that they did not routinely check or document hospice visits in the resident's records. The RN stated it was not her responsibility to monitor the hospice binder, and the LVN indicated she was unaware of previous hospice visits if she was not on duty. Both acknowledged the importance of documentation and the potential for missed care if visits were not tracked. The hospice case manager also confirmed that while she documented visits in the hospice provider's electronic health record, she did not always sign the facility's hospice binder due to its unavailability and did not record which facility nurse she checked in with during visits. Further, the hospice patient care manager stated that all hospice disciplines were required to sign in the hospice binder after each visit, and that case managers were responsible for ensuring all scheduled visits were completed and documented. The facility's DON expected charge nurses to document hospice visits and to check the hospice binder for compliance. Despite these expectations, there was a lack of documented evidence in the hospice binder to show that the resident received the ordered hospice services, and facility leadership acknowledged these findings during the survey.