Failure to Document Hospice Notification for Psychotropic Medication Refusals
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate medical record documentation regarding hospice notification when a resident refused psychotropic medications. A resident with diagnoses including paranoid schizophrenia and anxiety disorder, and with severe cognitive impairment per a recent MDS, required varying levels of assistance with ADLs such as showering, toileting, dressing, oral hygiene, and eating. During interviews, an LVN reported that she had notified hospice about this resident’s refusal of psychotropic medications but could not recall if she documented the notification. Review of the resident’s record did not show documentation of hospice being informed of the refusals. Additional interviews with another LVN and the DON confirmed that the facility’s practice and expectation were that licensed staff notify the physician or hospice when a resident refuses psychotropic or other medications, and that such notifications be documented in the resident’s progress notes so other staff are aware. The facility’s “Charting and Documentation” policy, revised July 2017, states that all services provided, progress toward care plan goals, and any changes in the resident’s condition must be documented in the medical record, and that the record should facilitate communication among the interdisciplinary team. The policy further requires that documentation be objective, complete, and accurate. The lack of documented hospice notification for the resident’s medication refusals was inconsistent with this policy and resulted in an inaccurate representation of the care provided.
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