Failure to Integrate and Communicate Hospice Status in Resident Care and Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to coordinate and integrate hospice services into a resident’s plan of care after hospice enrollment. A male resident with acute and chronic respiratory failure with hypoxia, ventilator dependence, anoxic brain damage, epilepsy, and a history of cardiac arrest had a hospice consent signed on 12/27/25 initiating hospice services. Despite this, review of the resident’s most current physician order sheet (POS) showed no physician orders for hospice, and the resident’s face sheet contained no indication of hospice status. The facility was unable to provide documentation demonstrating that hospice enrollment was incorporated into the resident’s active orders or clearly communicated to nursing staff responsible for the resident’s care. On 01/02/26, the resident experienced a change in condition characterized by a heart rate between 130–150 and seizure-like movements or activity. The RN on duty, working through an agency, notified the manager on duty, contacted the MD, obtained a telehealth consultation, and received an order to send the resident out via 911. The resident was transported to the hospital by EMTs. The RN documented that three copies of the face sheet and the physician orders were printed and given to the paramedics. The RN later stated she did not know the resident was on hospice at the time of transfer and indicated that hospice status would have been important to communicate to the hospital. Review of the SNF to Hospital Transfer Form for the 01/02/26 transfer showed that report was called in to the ER, but there was no indication on the form that the resident was on hospice. The DON stated that if a resident is on hospice, this should be reflected in the POS and on the face sheet, and that once hospice consent is signed, social services should enter the hospice order into the POS and usually inform the nurse on the unit. The facility’s hospice policy requires a documented communication process between the facility and hospice provider and specifies that the facility must immediately notify hospice of a need to transfer the resident. CMS regulations cited in the report require the facility to coordinate hospice services with the hospice provider and ensure hospice care is integrated into the resident’s plan of care, which did not occur in this case.
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