Failure to Coordinate Hospice Communication and Maintain Required Hospice Documentation
Penalty
Summary
The deficiency involves the facility’s failure to coordinate hospice communication and maintain required hospice documentation for a resident who had elected hospice benefits. Facility policy and the hospice service agreement required that hospice assessments and a hospice plan of care be integrated into the resident’s overall care plan, that hospice progress notes and communication be available in the medical record or hospice binder, and that hospice staff participate in care planning. The resident, admitted with terminal diagnoses including dementia, congestive heart failure, protein malnutrition, paranoid schizophrenia, and traumatic brain injury, elected hospice benefits, but the resident’s care plan only noted that hospice services were being received and lacked specific hospice responsibilities and interventions. The medical record did not contain a hospice plan of care, hospice election forms, physician certification of terminal illness, or hospice clinical notes. Staff interviews confirmed that hospice visit frequency, disciplines involved, and care instructions were not documented or known by facility staff. An LPN stated there was no documentation in the electronic record regarding hospice visit frequency, disciplines, or care instructions, and that the hospice binder contained no hospice documents or communication notes. A CNA reported that hospice aides provided care but was unaware of the days, times, or frequency of visits. The hospice RN stated that the hospice binder at the nurse’s station was empty and that hospice staff did not document in it after visits, and also reported not having attended or participated in any care plan meetings with the facility despite being the resident’s primary hospice nurse. The hospice RN further noted an issue with an updated POLST form that had been sent back to the facility for correction and had not yet been received back by hospice. The administrator acknowledged that the facility failed to ensure hospice communication was coordinated and that required documents were available and accessible to staff.
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