Failure to Document and Coordinate Hospice Services in Care Plans
Penalty
Summary
The facility failed to ensure proper collaboration and documentation between the nursing home and hospice services for two residents who were receiving hospice care. For one resident with diagnoses including heart failure, depression, overactive bladder, and morbid obesity, the care plan did not include any entries related to hospice services, despite the resident being admitted to hospice. The care plan only addressed activities of daily living and risk for skin breakdown, omitting identification of the hospice provider, services, supplies, medications, or equipment provided by hospice. Interviews with staff confirmed that this information should have been included in the care plan. For another resident with a history of hemiparesis, hemiplegia following a stroke, cerebral palsy, and dysphagia, the care plan also lacked any indication of hospice care or hospice provider services, even though the resident had been admitted to hospice. The hospice communication binder, which should have been available, was missing. Staff interviews revealed uncertainty about whether hospice information needed to be included in the care plan, and staff relied on nursing report sheets or direct communication to identify hospice status and services. The facility's own hospice policy required coordination and clear identification of responsibilities among the facility, resident, and hospice provider, as well as ongoing communication. However, the lack of documentation in the care plans and the absence of the hospice binder for one resident demonstrated a failure to follow this policy and ensure effective collaboration and communication regarding hospice services.