Failure to Ensure Hospice Enrollment and Timely Physician Notification
Penalty
Summary
A resident with multiple serious diagnoses, including COPD, kidney disease, heart failure, lung cancer, and dementia, was re-admitted to the facility with hospital discharge orders recommending a hospice evaluation and referral. The care plan and physician documentation indicated that the resident had elected hospice services, and interventions were outlined to work cooperatively with hospice to maintain comfort. However, the resident was not actually enrolled in hospice services upon re-admission, and no hospice orders were documented in the re-admission physician orders. Progress notes indicated that the hospice referral was initially made, but the referral was closed and a new referral was to be sent to a different hospice provider. There was no documentation confirming the resident's enrollment in hospice services prior to their decline and subsequent death. On the day of the resident's decline, staff noted a significant change in condition, including low blood pressure, irregular breathing, and low oxygen saturation. The LPN on duty attempted to contact the next of kin and notified the physician of the resident's declining status, but did not inform the physician that the resident was not enrolled in hospice services after discovering this fact. The LPN also failed to document the assessment and vital signs in the medical record, instead writing them on a piece of paper and forgetting to enter them later. The resident expired several hours after the change in condition, and there was no evidence that hospice services were initiated or that the physician was made aware of the lack of hospice enrollment. Interviews with facility staff and the physician confirmed that there was an expectation for the resident to be on hospice services, and that the physician should have been notified if the resident was not enrolled. The physician stated that, had he been informed, he would have considered sending the resident to the hospital for evaluation and treatment. The facility's policy required clinicians to be notified of changes in condition and for all assessments and vital signs to be documented in the medical record, but these procedures were not followed in this case.