Failure to Notify Hospice, Physician, and Family of Change in Condition for Hospice Resident
Penalty
Summary
The deficiency involves the facility’s failure to notify hospice, the physician, and the resident’s family of a change in condition for a hospice resident. The resident, who had diagnoses including chronic kidney disease, diabetes, GERD, acute embolism and thrombosis, anxiety, malignant pericardial disease, and dementia, was admitted with DNR/comfort care status and had orders for respiratory medications including ipratropium-albuterol four times a day for shortness of breath. A hospice care plan included an intervention to coordinate care and services between facility caregivers and the hospice company. On the date in question, the resident reported being short of breath and coughing until her chest hurt and requested to be sent to the hospital. The assigned nurse stated the resident had only a small cough, did not appear short of breath, and did not need hospital transfer, and attempted to administer cough medication instead. The resident then had her roommate call 911, and EMS arrived and transported her to the hospital. A progress note later documented that the resident had been admitted to a local hospital for shortness of breath, and another note indicated the resident’s son called and informed the facility that the resident had called 911 and was going to the hospital. The nurse acknowledged that, for a hospice resident with a change in condition, hospice, the physician, and family should be called, but she did not notify hospice, the physician, or initiate an emergency transfer. The DON stated an expectation that hospice, the physician, and family be notified when a resident has a change in condition. Facility policies on change in resident condition and hospice services required immediate notification of the resident’s physician and responsible party for significant changes in status and immediate notification of hospice for significant changes or need to transfer the resident, which did not occur in this case.
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