Failure to Document and Coordinate Hospice Care Services
Penalty
Summary
The facility failed to provide services in accordance with professional standards of care for a resident receiving Hospice care from an outside agency. The resident's medical record lacked documentation, including orders for Hospice, progress notes from medical providers, and a comprehensive care plan addressing Hospice services. Despite the facility's policy requiring nursing coordination and ongoing collaboration with Hospice, as well as the development and regular review of a resident-centered care plan by the interdisciplinary team, these requirements were not met. The electronic medical record did not contain any evidence of Hospice involvement, and communication about the resident's Hospice status was not documented or relayed to relevant staff. Interviews with facility staff and the Hospice provider revealed that while the resident did receive multiple visits from Hospice nurses, aides, and a social worker, the documentation of these services was not integrated into the facility's records. Staff were unclear about the process for documenting Hospice care, with some believing that notes were kept in a binder on the unit, while others, including the Medical Director, were unaware of such a system. The lack of communication and documentation resulted in the facility not having an order for Hospice or a care plan reflecting the resident's Hospice status, and the information about the resident's enrollment in Hospice was not properly conveyed to the admissions or care team.