Failure to Coordinate Hospice Care and Communicate Resident Status Across Shifts
Penalty
Summary
A deficiency occurred when the facility failed to ensure proper coordination and communication of hospice services for a resident receiving end-of-life care. The hospice registered nurse (HRN) informed a certified nursing assistant (CNA) during the morning shift that the resident was actively passing and should not be gotten out of bed, except in the case of a rally moment. This critical information was not communicated to the subsequent PM or night shift staff. As a result, the resident was gotten out of bed by night shift staff who were unaware of the resident's actively passing status, following the resident's usual routine. The resident in question had multiple diagnoses, including unspecified dementia and a lumbar vertebra fracture, and was under hospice care with an activated power of attorney for healthcare. On the morning in question, the resident exhibited signs of imminent decline, such as mottling, cool extremities, and increased pain during transfers. The hospice nurse had discussed with staff and family the need to focus on comfort measures, discontinue routine medications, and limit interventions to comfort medications as needed. However, the lack of effective communication between shifts led to the resident being transferred out of bed, contrary to the hospice nurse's instructions. Interviews and record reviews revealed that the facility's policy required collaborative communication and immediate notification of significant changes in a resident's condition. Despite this, the shift-to-shift reporting process failed, as the CNA who received the hospice nurse's instructions did not relay the information to the next shift, and the subsequent staff were not informed of the resident's change in status. This breakdown in communication resulted in the resident not receiving care consistent with their end-of-life needs as outlined in the coordinated hospice care plan.