Failure to Transcribe and Coordinate Hospice Medication Orders
Summary
Surveyors identified a deficiency in the facility’s coordination of hospice services for one resident receiving hospice care. The hospice contract effective June 3, 2022, required regular and as-needed communication between the hospice and the facility, with each party responsible for documenting such communications to ensure resident needs were met 24 hours per day. The contract also specified that if physician orders were inconsistent with the hospice plan of care or hospice protocols, facility nursing staff were to notify hospice so that hospice could resolve differences with the physician and secure necessary orders. Resident 38 had a quarterly MDS dated March 20, 2026, indicating cognitive impairment, need for staff assistance with daily care, receipt of antipsychotic and antianxiety medications, and enrollment in hospice services, with diagnoses including dementia, psychotic disorder, anxiety, and depression. A care plan dated January 8, 2025, stated that the facility would coordinate care with the resident’s hospice provider. Physician orders dated June 18, 2024, documented that the resident was receiving hospice services effective June 19, 2024. For symptom management, the resident had a current physician order dated March 14, 2025, for ABHR cream containing 1 mg Ativan per 12.5 mg Benadryl per 2 mg Haldol per 10 mg Reglan, to be applied topically twice daily for anxiety and psychosis. Hospice orders dated February 16, 2026, and April 13, 2026, specified a different ABHR formulation (1 mg Ativan per 25 mg Benadryl per 2 mg Haldol per 10 mg Reglan) and directions to apply one syringe to the wrist or neck every morning and evening for anxiety and agitation with care. There was no documented evidence that these hospice orders were transcribed into the resident’s physician orders, and the Nursing Home Administrator confirmed that the hospice orders were not transcribed and should have been, demonstrating a failure to coordinate care with the hospice provider as required.
Plan Of Correction
Resident 38 ABHR gel order was clarified and updated per physician on 4/24/26. Initial audit of current in-house resident Hospice recommendations will be reviewed to ensure orders are in place. Director of Nursing and/or designee will re-educate current in-house facility and agency nursing staff as well as newly hired or agency staff regarding the requirement to review hospice recommendations with visits and transcribing orders appropriately to the Medication Administration Record. Director of Nursing/designee will complete random audits of Hospice recommendations to ensure orders are generated and transcribed correctly weekly for 4 weeks and monthly for 2 months. Audit results will be reviewed by the facility Quality Assurance Performance Improvement Committee to determine compliance or need for continuation of audits.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
The facility failed to ensure effective communication and documentation of hospice services with a contracted hospice provider for three residents who had revoked services from one hospice and elected another. Each resident had serious conditions such as dementia, CHF, COPD, and acute kidney failure and was documented on the MDS as needing extensive ADL assistance and, in some cases, receiving hospice services. However, facility progress notes over the review period did not reflect hospice involvement, and the hospice communication book contained only isolated RN signatures without details of visits or care provided. The DON confirmed the absence of hospice documentation, and a hospice Business Development Director acknowledged that the hospice was behind on documentation and had not recorded visits, despite contractual and policy requirements for accurate records and coordinated care.
A resident with severe cognitive impairment and swallowing difficulties had a physician-ordered mechanical soft diet with honey thick liquids, while hospice documentation listed a soft/puree diet with honey thick liquids. Hospice staff reported they had soft/puree diet orders on file, and the facility’s MR staff stated they only uploaded hospice records without reviewing their contents. The DON confirmed that hospice records were not being reviewed for consistency, despite an agreement and policy requiring coordination and alignment between the hospice plan of care and the facility plan of care.
A resident receiving hospice care did not have their hospice records readily available at the facility, as required for effective collaboration between facility staff and the hospice provider. When surveyors requested the records, only a sign-in log was found, and the actual hospice notes had to be obtained from the hospice provider later that day. Staff interviews confirmed the records were not accessible at the time of request, contrary to facility policy.
A resident with severe cognitive impairment and multiple diagnoses was placed on hospice services, but the facility did not have any hospice documentation, including the plan of care, progress notes, or code status, available for review. The Administrator and DON confirmed that no hospice records had been received from the hospice provider.
A resident with advanced dementia and multiple health issues was admitted to hospice, but the facility failed to coordinate care with hospice staff. The resident developed a pressure injury that was not communicated to hospice, and documentation from both facility and hospice staff was incomplete or inaccurate. There was minimal communication between LPNs, hospice nurses, and the resident's family, and required protocols for care coordination and documentation were not followed.
A resident receiving hospice care did not have up-to-date hospice documentation maintained by the facility. Staff were unable to locate recent hospice notes, and the available records only included information up to March, with no documentation for subsequent months. The hospice provider confirmed timely transmission of records, but facility staff could not account for missing documentation, resulting in a failure to ensure proper hospice communication and recordkeeping.
Failure to Coordinate and Document Hospice Services With Contracted Provider
Penalty
Summary
The deficiency involves the facility’s failure to ensure an effective communication process and proper documentation of hospice services and coordination of care with Hospice Company A, as required by facility policy and the hospice contract. For one resident with hypertension, chronic kidney disease, dementia, and anorexia, the record showed admission to Hospice Company B and later revocation of those services, followed by election and admission to Hospice Company A for senile degeneration of the brain. However, the resident’s MDS did not reflect receipt of hospice services, facility progress notes for the relevant months contained no documentation of hospice involvement, and the hospice communication book for Hospice Company A contained only a single RN signature for a visit with no additional information about services provided. A second resident with CHF, dysphagia, adult failure to thrive, hypertension, and peripheral vascular disease was initially admitted to Hospice Company B and later revoked those services and elected Hospice Company A with a diagnosis of COPD. The MDS for this resident indicated severe cognitive impairment, dependence in ADLs, and receipt of hospice services, yet the facility’s progress notes for the same time period did not document hospice services. The hospice communication book for Hospice Company A again contained only one RN signature for a visit and no further documentation of hospice care or coordination. A third resident with acute kidney failure, hypertension, CHF, generalized anxiety disorder, and vascular dementia was admitted to Hospice Company B, revoked those services, and then elected Hospice Company A with a terminal dementia diagnosis. The MDS reflected that this resident was severely cognitively impaired, dependent in ADLs, and receiving hospice services, but the facility’s progress notes for the review period lacked any hospice-related documentation. The hospice communication book for Hospice Company A contained only a single RN signature for a visit and no other information. The DON confirmed the lack of hospice documentation in the facility records and hospice communication book for all three residents, and the hospice Business Development Director acknowledged that Hospice Company A was behind on documentation and had failed to document visits, despite a contract and facility policy requiring accurate records and a communication process for coordination of care.
Failure to Reconcile Hospice Diet Documentation With Facility Orders
Penalty
Summary
The deficiency involves the facility’s failure to ensure hospice documentation was reviewed and consistent with facility physician orders and the resident’s plan of care for a hospice patient. The resident was admitted with diagnoses including cerebral atherosclerosis, vascular dementia, anxiety disorder, hypertension, and bipolar disorder, and had severe cognitive impairment per the MDS. The MDS and quarterly nutrition reviews documented that the resident held food in the mouth/cheeks, had residual food after meals, and experienced coughing or choking during meals or when swallowing medications. The physician’s diet order specified a regular diet with mechanical soft texture and honey thick liquids. In contrast, hospice reports documented the resident’s diet as soft/puree with honey thick liquids, and the hospice nurse stated that hospice had diet orders on file for soft/puree and honey thick liquids. The DON reported that when hospice records are sent to the facility, the medical records department receives them and uploads them into the documentation system but does not review the contents. The DON further confirmed that the medical records department was not reviewing hospice records and could not confirm that anyone else was reviewing them. The hospice agreement and facility hospice policy required collaboration and consistency between the hospice plan of care and the facility plan of care, but hospice was documenting an incorrect diet that did not match the facility’s physician orders, and the facility did not have a process in place to review and reconcile these discrepancies.
Hospice Records Not Readily Available for Review
Penalty
Summary
The facility failed to ensure that hospice records were readily available for review, which impeded effective collaboration between the facility and the hospice provider. For one resident with diagnoses including vascular dementia, cerebral atherosclerosis, bone disorders, and hypertension, hospice services were arranged to include CNA visits three times per week, weekly nursing care, and monthly social services. Hospice staff were expected to provide care summaries to the facility after each visit. However, when surveyors requested hospice notes for this resident, only a sign-in log was found in the designated binder at the nurse's station, and no hospice care notes were immediately available. Staff interviews revealed confusion regarding the location of hospice records, with one RN believing the unit manager might have the notes, but they were not accessible at the time of request. The hospice notes were only provided later that day after being printed and forwarded by the hospice provider upon request. An LPN confirmed that the documents were not present in the facility and had to be obtained from hospice. Facility policy required designated staff to ensure communication and documentation with hospice providers, but this was not followed, resulting in the deficiency.
Failure to Maintain Hospice Documentation for Resident
Penalty
Summary
The facility failed to ensure that hospice records were present and accessible for a resident who had been placed on hospice services. Medical record review for this resident, who had multiple complex diagnoses including severe cognitive impairment, revealed that from the start of hospice care through a ten-day period, there were no hospice documents available in the facility. Specifically, there was an absence of the hospice plan of care, hospice progress notes, and documentation of the resident's code status. Interviews with the Administrator and DON confirmed that the facility did not have any hospice documentation on site, as hospice had not sent the required documents.
Failure to Coordinate Hospice Services and Ensure Continuity of Care
Penalty
Summary
The facility failed to coordinate care and services with hospice for a resident who had been admitted with multiple diagnoses, including severe dementia, malnutrition, and a history of falls. The resident was under palliative care and later enrolled in hospice, but the hospice care plan was incomplete, listing only assistance with feeding and lacking other necessary interventions. Documentation showed that the resident developed a pressure injury, but there was no evidence that hospice was notified of this change in condition, nor was there documentation of hospice involvement in the resident's ongoing care. Multiple assessments by facility staff and wound care practitioners identified and tracked the progression of the resident's pressure injury, including changes in wound stage and size. Despite these findings, hospice staff were not informed, and their own documentation failed to reflect the presence of the wound. Communication between facility staff and hospice was minimal or absent, with nurses reporting unsuccessful attempts to contact hospice and no updates or care coordination occurring. Hospice staff also did not communicate with facility staff or the resident's family, and their assessments did not accurately reflect the resident's condition. Interviews with facility staff, hospice staff, and the resident's family confirmed a lack of communication and coordination. There was no communication binder or process in place for sharing updates, and hospice staff did not follow established protocols for documenting visits or care provided. The facility's policy and the hospice contract both required collaboration and communication, but these were not followed, resulting in a lack of continuity of care for the resident.
Failure to Maintain Hospice Documentation and Communication
Penalty
Summary
The facility failed to maintain proper communication and documentation of hospice services for one resident who was admitted to hospice care. The resident, who had multiple diagnoses including psychotic disorder, dementia, malnutrition, and Parkinson's disease, was cognitively impaired and dependent on staff for mobility and eating. Although there was an order for hospice admission, the facility's records only included hospice documentation up to March 2025, with no evidence of notes or documentation for April or May 2025. The hospice binder at the nursing station contained only calendars with visit notations and lacked details about the visits, care provided, or staff involved. Comprehensive assessments and physician orders were present, but there was no documentation from the previous year or recent months. Staff interviews revealed confusion about the location and maintenance of hospice records. The LPN was unsure if updated records were maintained, the liaison could not locate current hospice documentation in the electronic medical record, and the DON confirmed that records were missing and only in the process of being scanned. The Director of Social Services provided additional documents, but the most recent were still from March 2025. The hospice RN confirmed that hospice sent weekly bundles of notes to the facility and tracked their delivery, denying any delay on their part. Facility policy required coordination of care for hospice patients, but the necessary documentation was not maintained as required.
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