Failure to Coordinate Timely Hospice Orders and Care
Penalty
Summary
The facility failed to ensure proper coordination of care with hospice services for a resident who was severely cognitively impaired and receiving hospice care for Alzheimer's disease and dementia. The resident experienced a decline in health, including difficulty chewing and swallowing, which prompted nursing staff to contact hospice for reassessment. The hospice nurse assessed the resident and documented that the physician would be contacted for a liquid antibiotic and a pureed diet order. However, the facility did not receive the necessary physician orders for the antibiotic and diet change until several days later. During this period, there was a breakdown in communication and follow-up between facility staff and hospice. Although the hospice nurse indicated that orders would be obtained, facility staff did not verify receipt of these orders in a timely manner. The delay was only discovered when the resident's family expressed concern about the lack of timely antibiotic administration. It was noted that hospice attempted to fax the orders multiple times without success, and verbal orders were eventually received and initiated by the facility. Interviews with facility staff and hospice personnel confirmed that there was a lack of follow-up to ensure that the physician orders were received and implemented. The nurse responsible acknowledged not realizing the orders had not been received until the family raised the issue. The Assistant Director of Nursing stated that staff should have followed up with hospice within a few hours or ensured the oncoming nurse was aware of the need for follow-up. The hospice nurse also confirmed that they were unaware the orders had not been received until contacted by facility staff several days later.