Failure to Coordinate Hospice Services and Ensure Continuity of Care
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.
Penalty
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A hospice-enrolled resident with multiple chronic conditions had scheduled Ativan and Dilaudid orders from the hospice medical director for symptom management. Facility staff administered early doses but did not document giving several later doses despite recorded pain levels, and the medical record contained no rationale for holding the medications. A hospice LPN later documented that an RN had withheld doses based on her own judgment, even after the resident’s family agreed with hospice’s recommendation to administer medications as ordered. There was no evidence the facility notified hospice of any change in condition or sought revised orders, contrary to facility policy and the hospice contract requiring documented communication and prohibiting unilateral changes to the hospice plan of care.
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 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 Follow Hospice Medication Orders and Communicate with Hospice
Penalty
Summary
The deficiency involves the facility’s failure to effectively communicate with a hospice agency and to follow hospice medication orders for a hospice-enrolled resident, as required by the hospice contract and facility policy. The resident, admitted in early March with diagnoses including muscle weakness, anxiety disorder, major depressive disorder, hypertension, and unspecified vascular dementia, was on hospice care with care plan interventions to administer medications as ordered by hospice and to maintain safety and comfort. On a specific date in late May, the hospice medical director ordered scheduled Ativan 1 mg by mouth every three hours starting at 3:00 A.M. and Dilaudid 4 mg every two hours starting at 2:00 A.M. Review of the Medication Administration Record showed that the resident received the early morning doses of Ativan and Dilaudid as ordered, but the midday doses of both medications were not documented as given. Specifically, the 12:00 P.M. and 3:00 P.M. Ativan doses and the 10:00 A.M. and 12:00 P.M. Dilaudid doses were not recorded as administered, even though the MAR documented pain levels of one and two at 10:00 A.M. and 12:00 P.M., respectively. The resident’s medical record contained no documentation explaining why these doses were held, and there was no evidence of communication with the hospice agency regarding any change in condition, medication concern, or rationale for altering the ordered regimen. An LPN confirmed that there was no indication or rationale in the record for holding the medications. Hospice records for the same date also showed no communication from the facility reporting a change in condition or requesting changes to the medication regimen. A hospice LPN documented that she visited the resident for periods of apnea and found the resident unresponsive to verbal and tactile stimuli and noted that the resident was receiving scheduled Ativan and Dilaudid, but that the facility RN had held doses based on her judgment that the resident did not need them. The hospice LPN discussed medication administration with the resident’s daughter, who stated she wanted the resident kept comfortable and agreed with hospice’s recommendation to administer medications as ordered. The hospice LPN then discussed the family’s wishes and the ordered medications with the facility RN, who remained unwilling to give the medications, and with the DON, who voiced understanding of the family’s request. The facility’s hospice contract required both parties to document communications, prohibited the facility from modifying the hospice plan of care without consulting hospice, and required immediate notification of hospice for changes in condition or inconsistent physician orders; these requirements were not met in this case, leading to the cited deficiency.
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 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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