Failure to Document Hospice Services and Orders in Resident Records
Penalty
Summary
The facility failed to provide a comprehensive description of the medication and equipment supplied by hospice services for a resident with diagnoses of congestive heart failure, diabetes mellitus, and gastroesophageal reflux. The resident was admitted to hospice services, but the Electronic Medical Record (EMR) did not include an order for hospice admission, and the order provided was only found on the hospice provider's certification form. Additionally, the Significant Change Minimum Data Set (MDS) was not completed following the resident's admission to hospice, and the Care Area Assessment (CAA) was not completed within the required 14-day period after the MDS was initiated. The resident's care plan documented the frequency of hospice nurse and aide visits but lacked details regarding the specific equipment and medications provided by hospice. Interviews with facility staff confirmed that care plans and Kardexes should include hospice information, such as equipment, medications, and services, but these details were missing. The facility's policy required written identification of hospice services and a physician's order with diagnosis and prognosis, but these requirements were not met for the resident in question.