Failure to Document and Order Hospice Care for Admitted Resident
Penalty
Summary
A deficiency was identified when a resident admitted to the facility, who was already receiving Hospice care at their prior facility, did not have any physician orders or progress notes entered to continue Hospice care upon admission. Record review showed that from the time of admission until discharge, there were no documented orders for Hospice services, nor any physician notes indicating awareness of the resident's Hospice status. The facility's policy requires a collaborative effort with Hospice providers and mandates a written agreement and documentation for residents with life-limiting illnesses, but this was not followed in this case. During interviews, the Medical Director confirmed that it is standard practice to write an order for Hospice care and acknowledged that there were no such orders or notes for this resident. The Medical Director stated they were unaware of the resident's Hospice status and had not seen any documentation or binders related to Hospice for this individual. The lack of physician documentation and orders for Hospice care was attributed to an oversight that went unnoticed by facility staff.