The resident at Fairfield Nursing & Rehabilitation Center had battled cancer for two years. It had spread to their brain. Ten rounds of radiation hadn't worked.
On February 15, nursing staff documented the resident's clear request: "Pt. and family states pt. wants hospice services. Pt stated [he/she] is tired and wants to go peacefully and comfortably r/t 2 yr. battle."
The resident had no appetite. Staff noted they made the primary care physician aware, and the doctor said to "contact hospice."
Then nothing happened for 12 days.
Medical records show no documentation of any hospice arrangements after that February 15 nursing note. The resident remained in the facility, dealing with escalating pain that reached 10 out of 10 on the pain scale in both hips by late February.
On February 27, when the resident was finally seen for pain management follow-up, Tylenol wasn't controlling the severe bilateral hip pain. Only then did the physician write orders for stronger pain medication and palliative care consultation.
The resident was eventually discharged home on March 5 with hospice services finally arranged to begin at home.
Inspectors found no physician order for hospice services dated February 15, despite the nursing documentation that the doctor had been contacted and said to arrange hospice care.
When questioned about the facility's hospice process, the Assistant Director of Nursing told inspectors that staff communicate requests to social work, "and they will reach out to Hospice and usually it would take a few days to get here."
The Director of Social Services initially said she didn't remember the resident. But when she called the hospice agency during the inspection, she learned something revealing about the facility's communication problems.
The hospice organization told her the resident had initially refused hospice services and they were cancelled on February 6. The resident was then signed up again for hospice on March 5.
But the resident hadn't even been admitted to Fairfield until February 12. The hospice cancellation happened six days before admission.
The social services director described a chaotic process for handling hospice orders. She told inspectors that traditionally, "the nurse will give the order to the social work, however now the physician comes directly to me and gives me the order."
When asked why the physician now bypassed nursing staff, she explained there had been persistent problems: "Sometimes they would bring the order to me and sometimes they would not. Now the physician brings them to me directly."
The Assistant Director of Nursing and another supervisor told inspectors they read nursing notes daily and that social work "should have gotten the Hospice consult" based on the February 15 documentation.
But nobody had arranged hospice care for nearly two weeks after the resident's explicit request.
During those 12 days, the resident experienced uncontrolled pain severe enough to require stronger medication. They waited in a facility focused on rehabilitation while seeking comfort care for terminal cancer that had already failed to respond to extensive radiation treatment.
The case reveals a breakdown in communication between nursing staff, social services, and physicians at a critical moment in end-of-life care. A resident facing death after a two-year cancer battle asked for hospice services to ensure peaceful, comfortable dying.
Instead, they got bureaucratic confusion and nearly two weeks of delay while experiencing severe pain that existing medication couldn't control.
The resident's sister had already spoken with a hospice nurse at the hospital before the nursing home admission. She wasn't sure whether her sibling was being admitted "for rehabilitation, palliative or comfort care."
By February 15, three days after admission, the resident had made their wishes clear. They wanted hospice services. They were tired of fighting. They wanted to go peacefully.
The facility's own policies required arranging hospice services or helping transfer residents to facilities that could provide them. Instead, communication failures left a dying cancer patient waiting for comfort care that should have been arranged immediately.
Federal inspectors cited the facility for failing to arrange hospice services for a resident who requested them. The violation affected the care of one resident during the complaint investigation.
The resident ultimately received hospice services, but only after discharge from the nursing home where they had clearly requested end-of-life care nearly two weeks earlier.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Fairfield Nursing & Rehabilitation Center from 2025-09-17 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Fairfield Nursing & Rehabilitation Center
- Browse all MD nursing home inspections