Failure to Document Hospice Evaluation and Admission in Resident Medical Record
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident who requested hospice services. The resident, who had diagnoses including encephalopathy, COPD, cognitive communication deficit, and bipolar disorder, expressed a desire to be evaluated for hospice and requested that staff contact family and initiate the process. Although the Director of Nursing was notified and instructed staff to begin the hospice referral, there was no documentation in the resident's medical record regarding a hospice referral, assessment, or admission to hospice services. Additionally, there was no physician's order for hospice evaluation or admission, and the care plan was not updated to reflect hospice services. Staff interviews confirmed that nursing staff are expected to document changes in health condition, including hospice evaluation and admission, and that physician orders for hospice should be present in the chart. The facility was unable to provide a policy related to nursing documentation and medical record accuracy. The absence of documentation regarding hospice services, including the lack of hospice records, orders, and care plan updates, resulted in an incomplete and inaccurate medical record for the resident.