Failure to Coordinate and Document Hospice Services for Resident
Penalty
Summary
The facility failed to designate an interdisciplinary team (IDT) member responsible for coordinating care and communication with hospice services for a resident receiving end-of-life care. Despite facility policy requiring a written agreement with the hospice provider, including a coordinated plan of care and clear assignment of responsibilities, there was no documentation of a designated IDT contact or evidence that the facility implemented the required agreement. The medical record lacked essential documents such as a physician's order to admit the resident to hospice, physician certification of terminal illness, the hospice election form, and a coordinated plan of care outlining the division of services between the facility and hospice. The resident in question had multiple complex diagnoses, including dementia, moderate protein-calorie malnutrition, and diabetes, and was dependent on staff for activities of daily living with severely impaired cognition. The resident was admitted to hospice services, but the facility's records did not reflect the necessary documentation or coordination. Nursing progress notes indicated that hospice was involved and provided medications, but there was no consistent documentation of hospice visits, services provided, or updated plans of care after certain dates. Wound care was being provided by both the facility's wound care provider and hospice, but there was no clear communication or coordination between the two, leading to overlapping and potentially conflicting care orders. Interviews with facility staff and the hospice case manager revealed a lack of awareness regarding the roles and responsibilities for hospice coordination. Staff were unaware of the requirement for a designated IDT contact, did not consistently receive or document hospice plans of care, and were unclear about the process for communication and documentation of hospice visits and orders. The hospice case manager was not informed about the facility's wound care provider's involvement, and facility staff did not know about the specialized wound care program offered by hospice. The process for enrolling residents in hospice and ongoing communication was described as broken and inconsistent, with missing documentation and unclear lines of responsibility.