Failure to Coordinate Hospice Code Status Communication
Penalty
Summary
The facility failed to coordinate care with a contracted hospice service provider for a resident who was admitted to hospice services. Despite the resident and their family previously declining to change the resident's cardiac code status from full code, a Do Not Resuscitate (DNR) document was later signed by the resident's guardian outside the facility, with a hospice representative as a witness. However, the facility was not notified of this change, nor was a copy of the signed DNR provided to the facility by the hospice provider. Subsequently, the resident experienced a decline in condition, exhibiting sluggishness and audible secretions, and was transferred to the emergency room as a full code. During transport, the resident was intubated, sedated, and paralyzed by emergency medical technicians. It was only after this event that the facility staff became aware of the signed DNR document and updated the resident's code status in the medical record accordingly. Interviews with facility staff revealed that there was no established process for ensuring timely communication of code status changes from the hospice provider to the facility. The hospice provider's representative admitted to not notifying the facility of the DNR status change and was unsure of the standard procedure for such notifications. Facility staff also indicated that without direct communication or documentation from the hospice provider, they could not update the resident's code status, especially when the resident or family was unavailable for care plan meetings.