Failure to Ensure Communication and Documentation for Hospice Services
Penalty
Summary
The facility failed to ensure effective communication and coordination between its staff and the hospice provider for a resident receiving hospice services. The resident, who had diagnoses including heart failure, atrial fibrillation, and anxiety disorder, was dependent for all transfers and was cognitively intact. The hospice focus care plan indicated that the facility should coordinate with hospice providers and reference the hospice care plan for the resident’s preferences and needs. However, interviews with LPNs revealed that the hospice binder did not contain a current hospice care plan, visit schedule, or documentation of hospice visits, and that hospice nurses did not communicate with facility staff about care provided or changes in the plan of care. Further interviews with the RN contact for hospice agencies and the DON confirmed that there was inconsistent communication from the hospice agency, and that the hospice plan of care and visit schedules were not present in the hospice binder or the electronic health record. The hospice registered nurse clinical manager stated that the hospice care plan had been sent to the facility but had not verified its receipt, and was unaware that the facility was not receiving visit schedules or documentation. The facility’s own policies and hospice agreement required collaborative care, documentation of hospice assessments and care in the facility chart, and verbal communication with staff after each visit, but these procedures were not being followed. The lack of documentation and communication meant that facility staff were not consistently informed about the care being provided to the resident by hospice, nor about any changes to the plan of care. This failure to maintain a communication process and ensure the availability of essential hospice documentation resulted in the facility not meeting its obligations to coordinate and deliver appropriate end-of-life care as outlined in its policies and agreements.