MercyOne Centerville Medical Center repeatedly violated its contract with hospice providers by failing to communicate critical changes in a resident's condition and treatment, federal inspectors found during an August complaint investigation.
The breakdown in communication lasted weeks and left hospice nurses unaware that facility doctors had discontinued or modified key medications for the resident under their care.
On July 7, the resident told staff "I feel sick, everywhere" before refusing her supper meal. Her vital signs showed a temperature of 98.1 degrees, pulse of 67, and oxygen levels at 93 percent. She also complained of burning with urination. Nurses noted her urine had a foul odor and dark color, and that she was taking fluids poorly despite encouragement.
Staff gave her anti-nausea medication and faxed an update to her primary care physician. But facility records show no notification was sent to hospice about the resident's changed condition.
The next day, the facility's nurse practitioner discontinued Colace, a medication used to treat constipation, during routine rounds. Again, no communication went to hospice. The hospice registered nurse later told inspectors she continued to have active orders for the resident to receive Colace 100 mg daily, unaware it had been stopped.
More than a month later, on August 12, the facility's medical director ordered staff to hold the resident's daily magnesium supplement due to episodes of diarrhea. The 400 mg daily dose was suspended so staff could monitor her gastrointestinal symptoms.
The hospice nurse didn't learn about this medication change until August 25 — nearly two weeks after it happened.
During the inspection on August 28, the facility's director of nursing acknowledged she was responsible for coordinating with hospice through emails and phone calls. She said reviewing hospice orders and care plans fell under her duties.
But she was unaware of discrepancies between hospice and facility orders, including conflicts over the resident's oxygen therapy.
The communication failures violated the facility's own contract with the hospice provider. The agreement, signed in July 2023, required MercyOne Centerville to "contact the hospice immediately for any significant change in condition and any clinical complications that could result in alteration in the Hospice Plan of Care."
The contract specifically included medications, treatments, care and services as areas requiring immediate communication. It designated the hospice registered nurse as responsible for overall coordination of the resident's care and required the facility to designate one person responsible for implementing the agreement.
Under the contract, the facility agreed to provide care and services according to the hospice plan of care, including medication administration. The hospice maintained responsibility for coordinating all aspects of the resident's end-of-life care.
The inspection revealed a pattern of poor communication that left the hospice team operating with outdated information about their patient's condition and treatment. While the resident experienced symptoms including nausea, urinary burning, foul-smelling urine, and diarrhea, her hospice providers remained unaware of both her declining condition and the medical responses to it.
The facility's director of nursing told inspectors she coordinated with hospice through various methods but failed to ensure critical information reached the care team when changes occurred. The breakdown meant hospice nurses continued following medication orders that facility doctors had already discontinued or modified.
Federal regulations require facilities to ensure hospice patients receive coordinated care between all providers. When facilities fail to communicate changes in condition or treatment, hospice teams cannot properly adjust pain management, symptom control, or other comfort measures that define quality end-of-life care.
The resident's experience of feeling sick "everywhere" while her care teams operated with conflicting information illustrates how communication failures can compromise the coordinated approach that hospice care promises dying patients and their families.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Mercyone Centerville Medical Center from 2025-08-28 including all violations, facility responses, and corrective action plans.
Additional Resources
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