Failure to Coordinate and Document Hospice Care Communication
Penalty
Summary
The facility failed to coordinate care for a resident who was receiving hospice services, resulting in a lack of communication and documentation between facility nursing staff and the hospice team. The resident developed swelling, redness, and pain in the left knee, which was initially diagnosed as cellulitis and treated with antibiotics and ibuprofen. Over time, the resident's condition worsened, with further swelling and pain noted. A hospice nurse assessed the resident and suspected a possible disarticulation (fracture vs. dislocation), discussed the situation with the resident's spouse, and decided not to send the resident to the hospital. However, this assessment and decision were not communicated to the facility nursing staff, who later noted a possible dislocation without knowledge of the hospice nurse's previous findings. Interviews with facility staff revealed that communication with hospice staff was primarily verbal and not formally documented. Hospice staff maintained their own paper documentation, which was not routinely shared or reviewed by facility staff. The facility's leadership confirmed that there was no documentation to show that the facility nursing staff acknowledged or discussed the hospice nurse's assessment and the decision made with the resident's power of attorney. This lack of coordinated communication and documentation led to a deficiency in the provision and coordination of hospice care for the resident.