Failure to Notify Hospice Provider After Resident Fall and Hospital Transfer
Penalty
Summary
The facility failed to communicate with the hospice provider when a change in condition was identified for a resident receiving hospice services. The resident, who had multiple diagnoses including seizures, bone disorders, anxiety, muscle weakness, and dementia with mood disturbance, was readmitted to the facility from an acute care hospital on hospice care. The resident's care plan required staff to notify the nurse, physician, and hospice provider of any noted changes in condition. On the date of the incident, the resident experienced a fall resulting in a nosebleed and a skin tear, and was subsequently transferred to the hospital. Documentation showed that the physician and family were notified, but there was no evidence that the hospice provider was informed of the fall or the hospital transfer. Interviews confirmed that the hospice provider was not notified of the resident's change in condition or transfer, and the DON acknowledged that hospice should have been informed and that such notification should have been documented. The facility's agreement with the hospice provider required immediate notification of any significant change in a hospice patient's status, including the need for hospital transfer. The lack of communication with hospice following the resident's fall and transfer constituted a failure to ensure collaboration on the provision of necessary care and services.