Lack of Physician Order for Hospice Services
Penalty
Summary
The facility failed to ensure that a resident admitted with multiple diagnoses, including stroke with right-sided hemiplegia and hemiparesis, vascular dementia, and adult failure to thrive, had a physician's order for hospice services. Documentation showed that the resident was admitted to hospice and was receiving regular hospice care and services, as indicated by hospice nurse progress notes and a Minimum Data Set (MDS) assessment, which coded the resident for hospice services. However, a review of the resident's medical record revealed that there was no physician order for hospice services present. Interviews with facility staff, including a unit manager and the DON, confirmed that hospice orders should be placed in the electronic medical record by the ordering provider, and that sometimes written orders could be kept in a hospice binder at the nurses' station. Despite these procedures, both the hospice binder and the electronic medical record lacked the required physician order for hospice services for this resident. The administrator also confirmed that residents receiving hospice care should have an order in the electronic medical record.