Failure to Collaborate and Document Hospice Services
Penalty
Summary
The facility failed to collaborate care with the hospice agency for a resident who was receiving hospice services. The resident, who had chronic obstructive pulmonary disease and dementia with severe cognitive impairment, was readmitted to the facility and had a care plan indicating a terminal prognosis and the need for hospice services. The hospice plan of care specified that the resident was to receive visits from a skilled nurse and a home hospice aide twice a week. However, documentation in the hospice binder showed missing records for skilled nurse visits during two separate weeks and incomplete documentation for home hospice aide visits, with some weeks lacking evidence of the required two visits. Interviews with staff revealed that the LPN believed the aide and nurse each visited once a week unless there was a change in condition, at which point additional visits would be requested. The DON stated that the unit manager was responsible for obtaining hospice visit documentation but acknowledged that supporting documentation for the visits was not available, despite the belief that visits had occurred. The administrator was unable to provide a copy of the hospice contract during the survey, as it could not be located and the hospice agency was unavailable after hours.