Failure to Notify Hospice of Resident’s Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to coordinate care with a hospice agency by not notifying the hospice provider of a resident’s transfer to the hospital. The resident was an elderly female with Alzheimer’s disease, aphasia, stroke history, short- and long-term memory problems, and severely impaired cognitive skills. She had been admitted to hospice services for Alzheimer’s disease. According to progress notes, an LVN documented that the resident pulled out her G-tube, the MD was notified, and an order was obtained to send her to the ER for G-tube replacement. The LVN arranged ambulance transport, and another LVN documented that the resident was transported to a named hospital, was stable, and that report was given to the hospital ER and the resident’s representative was notified. Record review of the eINTERACT Transfer Form showed the hospice company was not contacted about the transfer. During interviews, a hospice representative stated the hospice company was not informed of the resident’s hospital transfer and that they expected the facility to communicate when the resident went to the hospital. The DON stated that all nurses knew hospice agencies were supposed to be notified when a hospice resident had a change in condition or was sent to the hospital, and that the nurse on duty was responsible for this communication. The DON also stated she was not aware that hospice had not been notified and that nurse managers normally checked that all necessary parties were notified, but this was not done. An LVN reported he had told the oncoming LVN to call hospice about the transfer and assumed it would be done. The facility’s policy on Coordination of Hospice Services required immediate contact and communication with hospice staff, the attending practitioner, and the family/resident representative regarding significant changes, clinical complications, or emergent situations, which was not followed in this case.
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