Failure to Coordinate Care for Hospice Resident Results in Fall and Injury
Summary
The facility failed to ensure proper coordination of care between its staff and hospice staff for a resident receiving hospice services, resulting in a significant incident. The resident, a male with advanced dementia, hemiplegia, a history of falls, and multiple comorbidities, required total assistance for transfers, specifically with a mechanical lift and two-person assistance as documented in the care plan and physician orders. However, the hospice care plan did not reflect this requirement, and hospice staff were not consistently included in care plan meetings or provided with updated facility care plans. On the day of the incident, a hospice CNA attempted to transfer the resident from a shower chair to the bed without using the mechanical lift and without assistance, despite being aware of the resident's need for such support. The CNA reported being unable to find the sling for the lift and, after informing a facility LVN, was told it was acceptable to proceed with a manual transfer. During this process, the resident fell, sustaining a laceration to the forehead and a cervical spine fracture, which required hospitalization and ICU care. The incident was not immediately investigated by facility administration, and there was a lack of communication regarding the event until hospice staff later reported the failure to use the mechanical lift. Interviews revealed that hospice staff were not routinely invited to facility care plan meetings, and there was no established process for sharing or reconciling care plans between the facility and hospice. The hospice CNA admitted to sometimes transferring the resident without assistance due to lack of available staff or equipment. Facility and hospice staff both acknowledged gaps in communication and coordination, with hospice staff relying on their own care plans, which did not include the mechanical lift requirement, and facility staff not ensuring hospice staff were aware of or following the facility's care plan interventions.
Removal Plan
- The alleged perpetrator will not be returning to the facility.
- Out of cycle QAPI including this plan was presented to the Medical Director by the facility administrator. The medical director did not request changes to the plan.
- The Nursing staff/ current hospice agencies CNAs were in-serviced by facility DON/ADON and Regional Compliance Nurse on how to find the level of assistance required for transfer and mechanical devices required in the kiosk.
- Mechanical lifts were tagged with bright colored sign stating, two people required to operate the lift. This was done by the Maintenance Director. This will give a second opportunity for staff to be reminded prior to using the equipment.
- Facility Charge Nurses were in-serviced by the facility DON on how to read the facility Kardex.
- Current hospice agencies CNAs/facility nursing staff providing services to residents at the facility were in-serviced by the facility DON on how to review the residents Kardex located in the kiosk with the Charge Nurse prior to providing direct care to the residents to ensure that the staff is aware of the number of people required for transfers and use of any mechanical lifts. This will be randomly monitored by DON/ADON/Admin. To prevent the recurrence of falls and injuries.
- The facility Social Worker will be sending reminder emails to contracted hospice agencies to attend the required mandatory care plan meetings at the facility as scheduled. To ensure the coordination of services. This will be randomly monitored by Admin/DON/ADON.
- 100% of residents' records were reviewed to ensure that the information reflected in the Kardex/Care plans for any residents requiring assistance with transfer to include any assistive devices. This was done by DON/ADON and the Regional Compliance Team.
- Facility staff and current hospice agencies were in-serviced by the DON/ADON and compliance nurse on Abuse and neglect. No facility staff member or contract hospice agency staff will be allowed to provide care until receiving the in-service mentioned above.
- Hospice CNAs must sign in upon arrival and review the Kardex with the charge nurse to ensure the plan of care and level of assistance are understood before providing care. Education is posted at the nurse's station.
- All hospice staff must report to charge nurse and review Kardex. All hospice staff must report to the charge nurse upon arrival and review the Kardex before providing care. They must sign off that they have reviewed and understood the Kardex.
- In-service training on identifying and reporting abuse, neglect, and exploitation for hospice staff.
- Training addressed recognizing signs of abuse, neglect, and exploitation and the importance of timely reporting.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to Coordinate Hospice Services in Care Plans: The facility failed to coordinate hospice services with facility services for three residents receiving hospice care. One resident’s care plan did not include hospice needs despite hospice enrollment, and two residents’ comprehensive care plans lacked hospice agency contact information and access to the hospice 24-hour on-call system. The RNAC confirmed the omissions during interview; the residents had diagnoses including HTN, heart failure, kidney disease, diabetes, hypokalemia, and vitamin D deficiency.
A facility failed to ensure hospice services met professional standards for 3 sampled residents. Medical record review showed each resident was receiving hospice services, but none of the records contained a physician order for hospice referral or eval. An RCD confirmed that residents placed on hospice did not receive a physician order for eval and that the hospice used at the time had access to all resident medical records.
Incomplete hospice documentation and coordination for a resident receiving hospice services. The facility failed to maintain required hospice records for a resident with dementia who was receiving hospice care, including the most recent hospice POC, election form, terminal illness certification/recertification, hospice personnel contact information, hospice medication information, and physician orders. An RN said the hospice binder was incomplete and did not know the resident’s hospice visit frequency or involved personnel, and the DON could not provide the required hospice information.
A resident receiving hospice services, with dementia, psychotic disorder, anxiety, and depression, had a care plan stating that the facility would coordinate care with the hospice provider. The hospice contract required regular communication and documentation to ensure resident needs were met and specified processes for resolving inconsistencies between physician orders and the hospice plan of care. The resident had an existing physician order for ABHR cream with a specific drug formulation and dosing, while subsequent hospice orders changed the ABHR formulation and application instructions. These hospice orders were not transcribed into the resident’s physician orders, and facility leadership confirmed they should have been, resulting in a failure to coordinate hospice medication orders as required.
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.
A resident with COPD, moderate cognitive impairment, and limited mobility was receiving hospice services, but the facility failed to ensure proper communication and coordination with the hospice provider. Although the resident’s care plan noted hospice admission and general interventions such as assistance with ADLs, monitoring weakness, and observing pain medication effectiveness, it lacked essential hospice-related details, including hospice contact information, visit frequency, and what supplies, equipment, medications, and care hospice would provide. This omission occurred despite a hospice agreement requiring a coordinated plan of care and a facility policy assigning social services to coordinate care between facility and hospice staff.
Failure to Coordinate Hospice Services in Care Plans
Penalty
Summary
The facility failed to ensure coordination of hospice services with facility services to meet the end-of-life care needs of three residents. Review of the facility’s hospice policy showed that coordinated care plans for residents receiving hospice services were to include the most recent hospice plan of care and the care and services provided by the facility. For Resident R9, the record showed admission to hospice with a diagnosis of hypertensive heart disease, and the MDS indicated hospice care was received while a resident; however, the current care plan did not include a hospice care plan. During interview, the RNAC confirmed the facility failed to implement a care plan for Resident R9’s hospice needs. For Resident R24 and Resident R78, the records showed physician orders to admit each resident to hospice services. Their current comprehensive care plans did not include coordination details for hospice services, including contact information for the hospice agency or how to access the hospice’s 24-hour on-call system. During interview, the RNAC confirmed the facility failed to include this information in the plan of care and failed to ensure coordination of hospice services with facility services for these residents. Resident R24’s diagnoses included high blood pressure, kidney disease, and hypokalemia, and Resident R78’s diagnoses included high blood pressure, kidney disease, and vitamin D deficiency.
Missing Physician Orders for Hospice Referrals
Penalty
Summary
The facility failed to ensure hospice services met professional standards for 3 of 12 sampled residents. Medical record review showed that resident #7 began receiving hospice services on 3/31/26, resident #83 began receiving hospice services on 1/21/26, and resident #84 began receiving hospice services on 2/5/26, but none of the three records contained evidence of a physician order for a hospice referral or evaluation. During interview on 5/6/26 at 12:44 PM, the regional clinical director confirmed that residents placed on hospice did not receive a physician order for evaluation and that the hospice used at that time was given access to the medical record for all residents.
Incomplete hospice documentation and coordination for a resident receiving hospice services
Penalty
Summary
The facility failed to ensure that hospice services met professional standards for one of two residents receiving hospice care, Resident ID #11, who was admitted in March 2026 with a diagnosis including dementia and began hospice services that same month. Review of the electronic and paper medical records did not reveal the most recent hospice plan of care, hospice election form, physician certification and recertification of the terminal illness, names and contact information for hospice personnel involved in care, hospice medication information, or hospice physician and attending physician orders. During interview, an RN acknowledged that the hospice binder was incomplete and stated she was unsure of the frequency of hospice visits and did not know the personnel involved in the resident’s care. The DON was also unable to provide evidence that the facility had the required hospice information.
Failure to Transcribe and Coordinate Hospice Medication Orders
Penalty
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.
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 in Resident Care Plan
Penalty
Summary
The deficiency involves the facility’s failure to ensure an effective communication process and coordinated plan of care between the hospice provider and the facility for a resident receiving hospice services. The resident’s EHR showed a diagnosis of COPD and a BIMS score of 11, indicating moderately impaired cognition, with partial to moderate staff assistance required for most ADLs. The MDS documented that the resident was receiving hospice care, and the care plan, revised 02/17/26, noted limited physical mobility due to weakness, hospice admission on 10/31/25, and interventions such as assistance with ADLs, establishing a daily routine, encouraging activities of choice, monitoring and reporting increased weakness or tiredness to the physician, encouraging rest, and observing the effectiveness of pain medication. However, the care plan did not include hospice-specific communication details such as a contact number for hospice, what supplies, equipment, and medications hospice would provide, when hospice staff would be in the building, or what care hospice staff would provide. Record review showed the resident was admitted to hospice care on 10/31/25, and the Hospice Agreement dated 10/31/26 stated that hospice and the facility would jointly develop and agree upon a coordinated plan of care. Despite this agreement, the resident’s care plan lacked the required hospice coordination information. During observation on 04/20/26, the resident was seen sitting in a wheelchair in the hall across from the east nurse’s station without signs or symptoms of pain. On 04/22/26, an administrative nurse confirmed that the care plan did not contain information regarding hospice visits, phone numbers, or medical supplies hospice would provide. The facility’s Hospice Program Policy, revised 07/17, documented that social services would be designated to coordinate care provided by facility staff and hospice staff, but this coordination was not reflected in the resident’s care plan documentation.
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