Medical Suites at Oak Creek failed to maintain proper coordination with hospice services for Resident 127, who had a terminal prognosis and severe cognitive impairment. The resident scored just six out of 15 on a mental status assessment, indicating significant dementia.
According to the hospice plan of care, the resident was supposed to receive visits from both a skilled nurse and home hospice aide twice weekly. But facility records showed major gaps in documentation.
No skilled nurse visits were recorded during the weeks of August 31 and September 7. Only single visits were documented during the weeks of August 24 and September 14, falling short of the required twice-weekly schedule.
The home hospice aide documentation was equally spotty. No visits were recorded during the week of September 7. One visit was documented on September 3, but there was no record of a required second visit that week.
The resident's care plan emphasized close monitoring for pain, with instructions to "observe resident closely for signs of pain, administer pain medications as ordered and notify physician immediately if there is breakthrough pain."
When questioned about the missing documentation, staff gave conflicting accounts of the actual care provided.
Licensed Practical Nurse 6 told inspectors the aide comes once a week and the nurse comes once a week, unless there's a change in condition. This contradicted the hospice plan requiring twice-weekly visits from each provider.
The Director of Nursing acknowledged the documentation problems but insisted the visits actually occurred. "The hospice staff came twice a week even though the supporting documentation was not available," she said.
She explained that the unit manager was responsible for obtaining visit documentation from the hospice agency. But that manager wasn't available for questioning during the inspection.
The facility's Administrator couldn't even locate the hospice contract when inspectors requested it. "I called to get the contract but it is after hours, so I doubt that we will get a copy of it," he said during the exit conference. "I know we have a contract with them; I just cannot find ours."
The missing documentation created a serious coordination gap for a vulnerable resident who needed careful monitoring during end-of-life care. Without proper records, the facility couldn't verify whether the resident received required hospice services or identify potential gaps in pain management and comfort care.
Federal regulations require nursing homes to arrange for hospice services and coordinate care with hospice agencies. The facility's inability to track basic visit schedules violated these requirements.
The resident had been readmitted to the facility with chronic obstructive pulmonary disease and dementia. With severe cognitive impairment and a terminal diagnosis, proper hospice coordination was essential for ensuring comfort and appropriate end-of-life care.
The documentation failures extended beyond simple paperwork problems. Without accurate records of hospice visits, the facility couldn't ensure continuity of care or identify when residents might need additional support.
The inspection found that facility staff were unclear about basic hospice visit requirements, with the licensed practical nurse describing a once-weekly schedule that fell short of the actual twice-weekly plan.
Meanwhile, the Director of Nursing's claim that visits occurred despite missing documentation highlighted the facility's failure to maintain proper oversight of hospice services. Effective coordination requires accurate records, not assumptions about care delivery.
The Administrator's inability to produce the hospice contract during a federal inspection raised additional questions about the facility's management of external care relationships. Basic contractual documentation should be readily available, especially during compliance reviews.
For Resident 127, the documentation gaps meant potential interruptions in skilled nursing assessment and personal care assistance during a critical period. The resident's severe dementia made self-advocacy impossible, increasing reliance on facility staff to ensure appropriate hospice coordination.
The inspection revealed a breakdown in the fundamental responsibility to track and coordinate end-of-life care for one of the facility's most vulnerable residents.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Medical Suites At Oak Creek (the) from 2025-10-03 including all violations, facility responses, and corrective action plans.
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