F0684

D

Failure to Coordinate Hospice Care and Honor Diet Preferences for a Terminally Ill Resident

Lakeside, Arizona Survey Completed on 11-19-2025

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to coordinate with hospice and follow physician orders and resident preferences for diet and symptom management for a hospice resident with terminal pancreatic cancer. The resident had a hospital plan of care for a full liquid diet to continue indefinitely, but upon admission to the facility, a physician order dated August 29, 2025 prescribed a regular diet with diabetic preference, regular texture, and thin liquids. Hospice respite documentation listed diet as “as tolerated,” and a care plan revised on August 29, 2025 identified hospice involvement for terminal pancreatic cancer with an intervention to maintain comfort through nutrition/hydration. A subsequent care plan revision on September 3, 2025 documented that the resident was at risk for decreased/variable intake, with goals to avoid unsatisfied hunger or thirst and interventions noting the resident preferred a pureed diet, liquified per preference, and food preferences to be honored. However, the admission nutrition assessment referred only to “see tray ticket” for food and fluid preferences, and the tray ticket lacked documented likes, dislikes, and beverage preferences.

CNA task logs over a 30‑day look‑back period showed frequent refusals and low meal intake, with only two instances of 76–100% meal consumption and many episodes of refusal or 0–25% intake. Documentation of snacks offered was sparse, with entries on only 9 of 30 days. Progress notes on multiple dates, including September 4, 6, and 12, 2025, recorded that the resident had very poor appetite, nausea, abdominal pain, and difficulty or pain when swallowing mechanically altered diet, and on one day consumed only water and preferred to sleep. Despite these repeated observations of poor intake and swallowing difficulty, the clinical record did not show that hospice or the facility provider was notified of these issues, nor that specific comfort‑focused interventions were implemented in response. There was also no evidence in the record that the resident was actually on a mechanically altered diet at the time these complaints were documented.

The facility also failed to consistently notify hospice of a fall and related change in condition. An incident report dated September 7, 2025 documented a fall with a head abrasion and indicated hospice was notified late that night, but progress notes and the IDT fall review on September 8, 2025 only referenced notification of providers and family, without specifying hospice. The hospice Director of Clinical Services stated that hospice had not been notified of the fall or of the resident’s food intake issues, and that such information should have been relayed. Interviews with staff showed inconsistent understanding and practice regarding hospice notification: an LPN stated hospice should be contacted for falls and eating pattern changes, while the DON stated that for hospice residents it was not always necessary to involve hospice if the facility physician was managing care. Observations of meals on September 16, 2025 showed the resident receiving regular‑texture foods (toast, crispy bacon, scrambled eggs, hot dog and chips) that the resident described as too hard to eat given his cancer and need for soft or liquid foods, and the dietary manager reported no known issues and no listed preferences, despite the care plan indicating pureed/liquified preferences. These actions and omissions occurred despite facility policies and a hospice agreement requiring notification of hospice for significant changes in condition, coordination of care plans, documentation of communication, and accommodation of resident food preferences and significant variations in intake.