Failure to Enter Hospice Admission Order in Medical Record
Penalty
Summary
Facility staff failed to maintain an accurate and updated medical record for one resident when they did not document a hospice admission order upon the resident’s admission. The resident was admitted with diagnoses including unspecified severe protein-calorie malnutrition, acute and chronic respiratory failure with hypoxia, cachexia, and chronic diastolic (congestive) heart failure. Record review showed a physician telephone order dated 05/02/05 for the resident to be admitted to hospice, but review of the resident’s orders revealed no corresponding hospice admission order entered into the active medical record. During interview, the DON confirmed there was no active hospice admission order for the resident and stated that such an order should have been entered when the resident was admitted on hospice orders. This failure to transcribe and enter the hospice admission order into the resident’s medical record resulted in the record not reflecting the physician’s hospice admission order for the resident.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.