Failure to Provide and Document Hospice Services and Assessments
Penalty
Summary
The facility failed to ensure that two out of three residents reviewed for hospice care received appropriate end-of-life care. For one resident with chronic kidney disease and malignant cancer, the facility did not establish a collaborative plan of care for hospice services, and routine assessments and physician orders were not completed. Although hospice was notified and assessed the resident upon readmission from the hospital, the facility did not document further assessments of pain, discomfort, restlessness, or oxygen saturation after the initial hospice visit. No as-needed medications were administered between readmission and the resident's death, and required routine observations were not documented. For another resident with large B-cell lymphoma, the facility also failed to include a hospice care plan in the resident's care plan. Physician orders for pain assessments and supplemental oxygen were not consistently followed, as oxygen levels were not assessed every shift as ordered. After administration of PRN pain medication, there was no documented reassessment to monitor the effectiveness of the medication. Facility policy required documentation of all treatments and services, but this was not consistently done for these residents receiving hospice care.