Failure to Implement Hospice End-of-Life Recommendations and Monitor Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that hospice services met professional standards and that hospice recommendations were communicated, implemented, and documented for a resident receiving end-of-life care. The resident, admitted in January 2026 with diagnoses including Alzheimer’s disease, hypertension, and atherosclerotic heart disease of the native coronary artery, was on hospice services. A facility policy titled “Coordination of Hospice Services Policy” stated that the facility would communicate with hospice, identify and follow all interventions put into place by hospice and the facility, monitor medications and medical supplies provided by hospice as indicated in the plan of care, and provide ongoing monitoring of resident conditions. On 1/30/2026, hospice documentation showed that during an end-of-life visit between 4:00 PM and 5:00 PM, the hospice RN assessed the resident as having periods of apnea, a racing pulse, increasing pain, and agitation, with any movement causing groaning and grimacing. The hospice RN recommended scheduling Morphine concentrate 5 mg every 2 hours and Ativan concentrate 0.5 mg every 2 hours, with PRN orders for Morphine 5 mg every hour and Ativan 0.5 mg every hour for breakthrough symptoms. Record review revealed that earlier on 1/30/2026 at 11:55 AM, facility staff had spoken with hospice about the resident’s respiratory rate of 30 and restlessness and received a recommendation to increase the frequency of PRN medication from every 4 hours to every 2 hours, which the physician approved. However, further review of the clinical record, including progress notes, physician’s orders, and the MAR, failed to show that the additional hospice recommendations from the late afternoon end-of-life visit were communicated to the physician or implemented. The MAR showed the last dose of Ativan was given at 10:00 PM on 1/30/2026 and the last dose of Morphine at 2:13 PM on 1/30/2026, approximately 8 and 16 hours, respectively, before the resident’s death at 6:17 AM on 1/31/2026. Additionally, there were no nursing progress notes documenting assessment of the resident’s condition between 11:55 AM on 1/30/2026 and the time of death, despite the facility policy requiring ongoing monitoring. During interview, the DON acknowledged that the resident did not receive Morphine and Ativan per hospice recommendations and that there was no evidence of ongoing monitoring of the resident’s condition at end of life.
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