Lack of Hospice Documentation and Coordinated Care Plans for Hospice Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure hospice services met professional standards for two residents receiving hospice care by not maintaining hospice documentation or a coordinated plan of care. One resident with a diagnosis of senile degeneration of the brain had a physician’s order for hospice admission, but the medical record contained no documentation from hospice staff regarding services provided and no coordinated plan of care delineating which services hospice was responsible for and which the facility was responsible for. The hospice binder at the nurse’s station also lacked any documentation of hospice services or a coordinated care plan for this resident. An LPN reported that the hospice provider did not give the facility documentation of services, that she had not seen a coordinated care plan, and that she was unsure which days hospice staff were expected to see the resident or what services hospice versus facility staff were supposed to provide. The ADON confirmed that hospice documentation and a coordinated care plan should have been available in the hospice binder or the resident’s record, but none existed, and stated that the hospice provider did not provide documentation regarding services for this resident. A second resident with COPD was also admitted to hospice services per physician order, but the resident’s medical record contained no documentation from hospice staff regarding services provided. The ADON confirmed that this hospice provider did not provide documentation of care, that if hospice staff did not speak directly with facility staff the facility would not know what services were provided, and that staff had no documentation to review to determine what hospice services had been delivered. The medical records clerk confirmed that the hospice provider did not provide any documentation for either resident, despite the expectation that hospice providers submit visit notes after each visit so they could be scanned into the medical record and placed in the hospice binder. The Regional Clinical Nurse confirmed that each hospice resident should have a coordinated care plan delineating hospice versus facility responsibilities, that staff should know where to locate it, and that hospice staff are expected to provide documentation every time they visit a resident.
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