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:
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.
Hospice communication for a resident on hospice was incomplete because the binder at the nursing station contained only contact information, a CNA sign-in sheet, and a few shower sheets, but no hospice visit notes or hospice care plan. An LPN, CNA, and the DON acknowledged the binder had limited information and should have included additional hospice documentation.
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.
Hospice documentation was not sufficient or available for facility staff to review for two residents receiving hospice services. The facility had visit logs for hospice aides, RNs, and a chaplain, but no documentation of the actual care, assessments, or treatments provided, and the DON stated staff had to call hospice for information because they did not have access to hospice notes. Hospice RN also stated the hospice care plans were not developed in collaboration with facility staff and routine documentation was not provided to the facility.
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.
Missing hospice communication documentation affected two residents receiving hospice services. One resident had multiple chronic conditions and required hospice, but the facility had no documentation from hospice visits in the chart. For the other resident, the hospice communication book lacked daily or weekly logs, IDG notes were delayed, and facility documentation showed hospice involvement was often verbal with limited written follow-up after clinical events.
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.
Hospice Communication Binder Missing Care Plan and Visit Documentation
Penalty
Summary
The facility failed to establish a communication system with hospice and failed to ensure the hospice plan of care was readily available for staff review for one resident receiving hospice services. Resident #78 was admitted to the facility on 12/28/23 and had diagnoses including Alzheimer's disease, epilepsy, diabetes mellitus, cerebrovascular disease, and vascular dementia. The MDS assessment showed cognitive impairment and dependence on staff for bed mobility and transfers. A physician order dated 02/11/26 showed the resident was admitted to hospice on 02/11/26 for cerebrovascular disease. Review of the hospice communication binder on 03/04/26 showed it contained only the names and contact information for hospice staff, along with a sign-in sheet completed only by the hospice CNA and a few shower sheets. It did not include visit notes, the hospice care plan, or other hospice documents. During interview, LPN #626, CNA #710, and the DON acknowledged the binder had limited information and should have included additional hospice documentation such as visit notes and the hospice care plan. The facility policy stated the hospice shall maintain the hospice care plan and the facility shall maintain its own comprehensive care plan.
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.
Hospice documentation and care plan coordination were insufficient
Penalty
Summary
The facility failed to ensure hospice documentation was sufficient and available for facility staff to review so that assessments, treatments, and care planning were provided according to the hospice plan of care. For Resident #58, who was admitted with diagnoses including non-Hodgkin's lymphoma and heart failure and was documented as having impaired cognition, being dependent for ADLs, and receiving hospice services, the hospice binder at the nurses station listed hospice aide visit dates but did not include documentation of the care provided. RN #257 confirmed the facility had no charting for bathing or shampooing because hospice completed that care, and the DON stated facility staff did not have access to hospice medical records or visit notes and had to call hospice for information. The facility also did not jointly collaborate with hospice to develop resident care plans. Hospice RN #400 stated she did not develop Resident #58's hospice care plan in collaboration with facility staff and did not review the facility care plan to ensure hospice services were identified, and she had not routinely provided documentation of visits, assessments, or treatments to the facility. For Resident #23, who had diagnoses including dementia, atherosclerotic heart disease, and CHF and was admitted to hospice, the facility had a visitation binder showing hospice visits but no documentation of the services provided. RN #254 confirmed the facility had only a log of hospice staff visits and no documentation regarding the services provided, while Hospice RN #400 confirmed hospice documented on mobile devices and the facility did not have access to those notes.
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.
Missing Hospice Communication Documentation
Penalty
Summary
The facility failed to maintain hospice communication records and documentation for two residents receiving hospice services. One resident was admitted with multiple diagnoses including obesity, GERD, hypertension, obstructive sleep apnea, hyperlipidemia, gout, dysphagia, anxiety, diabetes mellitus, peritonitis, insomnia, and malignant neoplasm of the neck, and the MDS indicated she was mildly cognitively impaired, dependent on staff for medication administration, and required hospice services. Staff confirmed the facility did not have documentation from hospice visits, and the hospice case manager stated the facility should have a hospice communication binder containing all aspects of care provided by hospice, including visits from hospice team members. The Administrator later confirmed hospice notes and communications were faxed to the facility during the survey and that hospice communication should be part of the resident’s medical record and kept up to date and accurate. For the second resident, the record showed hospice services were provided by Heartland Hospice for a terminal diagnosis with a prognosis of six months or less if the disease followed its normal course. Diagnoses included cognitive communication deficit and shortness of breath, and the resident was incontinent of bowel and bladder. The hospice communication book contained care plan information and medications, but no daily or weekly communication logs, and IDG meeting notes were last uploaded with a two-week gap and no specific evidence of ongoing hospice communication during that time. Facility documentation showed hospice involvement in resident care, but communication was inconsistent and often verbal only, with limited written follow-up after events such as a visible pacemaker wire and an episode of unresponsiveness with verbal orders for a UA culture and continued monitoring.
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