Failure to Notify Hospice of Resident Status Changes
Penalty
Summary
The facility failed to effectively communicate and coordinate with hospice representatives regarding a resident who was receiving hospice services. Specifically, the facility did not notify hospice when the resident experienced a fall and when bruises were identified on her left forearm. Record reviews showed that there was no documentation indicating hospice was informed of these incidents, despite the facility's policy requiring notification of hospice for significant changes in a resident's physical, mental, social, or emotional status. Interviews with facility staff, including the DON and nurses, confirmed that hospice was not notified of these changes, and staff were either unaware or could not recall if notifications had been made. The resident involved was an elderly female with diagnoses including dementia, hypertension, and stroke, and was severely cognitively impaired, requiring extensive assistance with activities of daily living. She was admitted to hospice care and had a care plan addressing her terminal prognosis and associated risks. Despite these needs, the lack of communication and documentation between the facility and hospice resulted in a failure to ensure that hospice could assess and coordinate care in response to changes in the resident's condition.