Failure to Maintain Required Hospice Documentation
Penalty
Summary
The facility failed to ensure that the designated interdisciplinary team member obtained and maintained the required hospice documentation for a resident receiving hospice services. According to facility policy, all hospice assessments, plans of care, progress notes, and services provided must be integrated into the resident's medical record, and nursing staff are responsible for ensuring that current physician orders, progress notes, and hospice documentation are available. For one resident who was cognitively impaired, dependent on staff for daily care, and diagnosed with dementia, there was an active physician's order and care plan for hospice services. However, as of the date of review, there was no documented evidence in either the resident's clinical record or the hospice provider's record that updated hospice nurse aide or registered nurse charting had been obtained or maintained. This was confirmed by the DON, who acknowledged that the required hospice documentation was missing from both records, despite the resident's ongoing hospice care.