Failure to Integrate and Communicate Hospice Status in Resident Care and Hospital Transfer
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.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
The facility failed to have a signed hospice agreement in place before hospice services were provided to one resident, and it also failed to document communication with hospice about another resident’s repeated refusals of glaucoma eye drops. The resident receiving the eye drops had Alzheimer’s disease, severe cognitive impairment, and a terminal prognosis, and the MAR showed multiple missed doses over several months with no documented hospice notification. Staff stated they documented refusals on the MAR but did not call hospice each time or document conversations with the hospice nurse.
A resident admitted to hospice care and later expired had no documented coordinated plan of care between the facility and the hospice provider. The hospice form for coordinated care was left blank, including scheduled visits and signatures, and the DON and ADMN confirmed the care coordination documentation was not completed even though the facility policy and service agreement required coordination with hospice in the resident’s plan of care.
Failure to Coordinate Hospice Services With Facility Care: A resident with dementia and ESRD was admitted to hospice, but the facility did not integrate hospice services into the resident’s comprehensive care plan. The hospice communication tool did not address multiple care areas, including pain-related behavioral symptoms, antipsychotic medication risks, COPD-related respiratory impairment, skin breakdown, neurological deficits, sleep issues, altered cognition, and ADL limitations, and the NHA and DON could not provide documentation showing coordinated hospice care.
Incomplete hospice binders and missing care coordination documents. The facility did not keep current hospice paperwork available for residents receiving hospice services, including certification of terminal illness, IDG meeting records, recertification forms, election forms, medication profiles, and the most recent POC. Interviews showed the hospice RN, hospice marketing staff, and DON were unsure who was responsible for keeping the binders updated, and several resident binders contained only older or incomplete hospice records.
Missing Current Hospice Plan of Care: A resident receiving hospice services had a hospice binder that did not contain the most recent hospice POC. The resident had dysphagia, schizophrenia, HTN, and severely impaired cognitive skills, and was dependent on staff for toileting, bathing, and personal hygiene. The HCM said the POC should be in the binder and updated weekly, while the SSD stated she had not been checking the binders to ensure the current POC was obtained.
A resident receiving hospice for CVA had a hospice plan of care listing aide, SN, and spiritual counselor visit frequencies, but the facility did not integrate those details into the care plan. IDT notes showed continued hospice services and intent to integrate care, yet hospice staff were not documented as participating in the IDT meetings, and the facility RN and hospice RN did not complete the integrated plan of care. The SSD verified the hospice team was not included in the resident's IDT process and that the facility care plan was not updated to reflect the hospice plan.
Missing Hospice Contract and Failure to Communicate Medication Refusals
Penalty
Summary
The facility failed to have a written hospice agreement signed by authorized representatives of both the hospice and the LTC facility before hospice care was furnished to a resident receiving hospice services. For one resident admitted with heart disease and receiving hospice care, the facility could not locate a hospice contract in its contract binder. The administrator stated he was unable to find a contract with the resident’s hospice provider and was waiting for the hospice company to send one, and he stated the contract should have been in place before the resident was admitted on hospice services. The facility also failed to communicate and document communication with the hospice provider regarding another resident’s care needs. That resident had Alzheimer’s disease, severe cognitive impairment with a BIMS score of 00, behavioral symptoms, and a terminal prognosis with hospice services in place. The resident had orders for glaucoma eye drops, but the MAR showed multiple refusals and missed doses across February, March, April, and May. The record review found no documentation that the hospice provider was notified of these refusals, and progress notes also showed no evidence of communication with hospice about the eye drop refusals. During observation, a nurse attempted to administer the eye drops and the resident refused by closing his eyes and pushing the nurse away. In interviews, the nurse stated she documented the refusals on the MAR but did not call hospice each time and did not document conversations with the hospice nurse. Another nurse stated she would let hospice know if the hospice nurse happened to be in the building but did not call every time the resident refused. The resident’s representative stated she was aware the eye drops were not being given and was concerned about the resident’s vision and behavior, and she was unsure whether the facility was notifying hospice after the refusals.
Missing Hospice Care Coordination Documentation
Penalty
Summary
Failure to arrange for hospice services or assist with transfer to a facility that would arrange hospice services occurred for one resident who was admitted to hospice care and later expired in the facility. The resident’s face sheet indicated the resident was self-responsible for decision making, and the MDS showed a BIMS score of 13/15. The physician ordered a hospice referral and then admission to hospice care for cerebral atherosclerosis, and nursing progress notes documented that the resident was placed on hospice care. A hospice document showed an admit date and diagnosis of cerebral atherosclerosis, but the sections for nurse, social worker, chaplain, and nurse aide scheduled visits were left blank and incomplete. The hospice provider’s document titled Coordinated Care Plan for Facility Patients was also left blank, with no documented coordinated care plan between the facility and hospice provider. That document did not show that the plan of care and coordination were reviewed and signed by the resident, facility staff, and hospice staff. During interviews, the LVN stated that lack of documented care coordination increased the risk of confusion for nursing staff in meeting the resident’s care needs and addressing the medical condition. The DON confirmed there was no documented care coordination and stated the hospice provider should have completed the document and reviewed it with facility staff and the resident, while the ADMN stated the hospice provider should have completed the care coordination documentation before the resident was admitted to hospice care. The facility policy required collaboration with the hospice representative and coordination of facility staff participation in the hospice care planning process, and the service agreement required the facility to coordinate with hospice in developing a plan of care for each hospice patient.
Failure to Coordinate Hospice Services With Facility Care
Penalty
Summary
The facility failed to ensure the coordination of hospice services with facility services to meet the needs of Resident 119 on a daily basis. Resident 119 was admitted to the facility with diagnoses including dementia and end-stage renal disease and was admitted to hospice services on April 22, 2026, related to dementia and suspected osteomyelitis. A clinical record review showed the resident’s plan of care was not integrated with hospice services or with measures to ensure nursing facility staffing coordinated and monitored resident care in conjunction with the hospice provider. The comprehensive plan of care did not integrate hospice care and interventions for multiple identified needs, including potential pain-related behavioral health symptoms related to end-stage renal disease, risk for adverse effects related to antipsychotic medication use, risk for respiratory impairment related to COPD, actual skin breakdown related to impaired mobility, moisture, and refusals for care, neurological deficiencies related to metabolic encephalopathy, sleep cycle issues related to medications and sleeplessness, altered cognition and impairment related to dementia, and activities of daily life deficiencies related to dementia and physical limitations. During observation, the hospice communication tool at the nursing station did not contain or account for these care areas or corresponding interventions hospice staff perform. The NHA and DON were unable to provide documented evidence that hospice care services were integrated into a comprehensive care plan for Resident 119.
Incomplete hospice binders and missing care coordination documents
Penalty
Summary
The facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for residents receiving hospice services. During record review and interviews, the hospice binders for multiple residents were found to be incomplete or missing current hospice documentation, including physician certification of terminal illness, interdisciplinary group (IDG) meeting records, recertification forms, election forms, medication profiles, and the most recent plan of care. For one resident with dementia, muscle weakness, anxiety, and depression, the hospice binder did not contain the physician certification of terminal illness, the last two IDG meetings, or an updated recertification form. The last recertification in the binder covered an earlier certification period. The hospice RN stated that the binder should contain supporting hospice documentation and that the missing IDG meetings and recertification had not been delivered to the facility. The RN also stated that the documentation should be updated after the IDG meetings and that the binder was important for the facility to know the care and services being provided. For another resident with senile degeneration of the brain and major depressive disorder, the hospice binder contained an older IDG meeting but did not contain the current hospice IDG meeting. The hospice RN stated that an IDG meeting had occurred but was not in the binder, and the hospice regional marketing coordinator stated she was responsible for printing and delivering updated paperwork after each meeting. For a third resident with cerebrovascular disease and gastroesophageal reflux, the hospice binder was missing the updated hospice election form, certification of illness, IDG meetings, most recent medication profile, and most recent plan of care. Staff interviews reflected that the paperwork should have been in the facility binder on admission, but it had not been checked or provided as expected.
Missing Current Hospice Plan of Care
Penalty
Summary
The facility failed to ensure the most recent hospice plan of care was obtained for one resident receiving hospice services. Resident 12 was admitted and later readmitted to the facility, and had diagnoses including dysphagia, schizophrenia, and hypertension. The resident's MDS dated 4/24/2026 indicated severely impaired cognitive skills for daily decision making, dependence on staff for toileting, bathing, and personal hygiene, and receipt of hospice care. During a phone interview on 5/19/2026, the Hospice Case Manager stated the hospice plan of care should be present in the resident's hospice binder and updated weekly. However, during a concurrent interview and record review, Resident 12's hospice binder did not contain the most recent plan of care. The RN stated that having the most recent plan of care accessible was important because it addressed interventions and resident-specific goals. The Social Services Director stated she was the hospice coordinator and had not been checking the hospice binders to ensure the most recent plan of care was obtained, and the DON stated the hospice plan of care was important because it supported collaboration between the facility and hospice agency and ensured the resident's needs were being followed and addressed.
Hospice Care Plan Not Integrated With Facility IDT Process
Penalty
Summary
The facility failed to provide necessary care and services for one of two final sampled residents, Resident 63, who was receiving hospice services for a CVA (stroke). The deficiency involved the facility not ensuring hospice staff were included in Resident 63's interdisciplinary team meetings to discuss the resident's plan of care, and not ensuring the hospice plan of care was integrated into the facility's care plan with the frequency of visits and provisions of care from each hospice discipline. Resident 63 had a physician's order dated 10/4/25 to admit the resident to Hospice Provider A under routine care. The hospice plan of care dated 10/8/25 listed visit frequencies for the hospice aide, skilled nurse, and spiritual counselor. However, the facility's care plan for end of life and hospice admission did not include the frequency of visits by each hospice staff member or the services provided by each discipline. The document titled Hospice Provider A- Integrated Hospice and Facility Plan of Care was also not completed to include the frequency of hospice nurse and hospice aide visits and was not signed by the hospice RN or the facility RN. Review of the IDT Conference Notes dated 1/1/26 and 4/3/26 showed Resident 63 continued with hospice services and that care was to be integrated with the hospice team, but the notes did not show hospice staff participated in the IDT meetings. During interview and record review, the SSD stated he was responsible for coordinating hospice resident care and verified the IDT meetings for Resident 63 did not include Hospice Provider A staff and that he could not find documentation that hospice was informed or contacted to attend. The SSD also verified that an IDT meeting was not conducted to discuss Resident 63's hospice plan of care and that the facility care plan was not updated to incorporate the hospice plan of care. The DON, ADON, and Administrator were informed and acknowledged the findings.
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