San Antonio West Nursing: Hospice Care Plan Failures - TX

During a federal inspection on April 10, the DON at San Antonio West Nursing and Rehabilitation admitted she "did not know who was responsible and had forgotten about that task" when asked about monitoring hospice care plans for residents receiving end-of-life services.

The confession came during an investigation into how the facility handled hospice coordination for Resident #14, whose oxygen orders had recently changed from continuous to as-needed but whose updated care plan never made it into the facility's records.

LPN J, who provided direct care to Resident #14, told inspectors she spoke with the hospice nurse during every visit but never touched the hospice binder containing the resident's care plans "because it was the hospice's records." The licensed practical nurse had no idea whether Resident #14's care plan was current or outdated.

Assistant Director of Nursing E was equally clueless. She couldn't identify who was responsible for monitoring and coordinating hospice care plans during her interview at 2:14 p.m.

The breakdown meant Resident #14's most recent hospice care plan, dated April 8, never reached the facility's nursing staff through proper channels. Instead, RN O from Hospice G had to verbally relay the oxygen order change to LPN J after her weekly visit.

RN O, Resident #14's hospice care manager since late October 2025, explained the dangerous gap to inspectors. She said some facilities wanted hospice care plans faxed or emailed, but she wasn't typically responsible for sending those documents. When she received new physician orders after her weekly visits, she would give them verbally to the facility nurse.

"The impact of the facility not having Resident #14's most recent hospice care plan was Resident #14 may not receive the proper medication if the facility and hospice were not on the same page with medications," RN O told inspectors.

The hospice nurse noted that Resident #14 had remained stable despite the coordination failures.

But the DON acknowledged the serious risks during her interview at 4:40 p.m. She admitted there was a hospice binder at the nurses' station that hospices delivered, but "could not state if anyone checked the binders for documentation."

"The impact of a resident not having a current hospice care plan was if the hospice care plan had changed and the facility was not updated on the change, then the facility was not following the same plan of care," the DON told inspectors.

The Administrator tried to shift responsibility during his interview at 5:28 p.m., stating that nurse managers, assistant directors of nursing, and the DON were responsible for coordinating with hospices and "holding the hospices accountable in providing the documentation."

Yet none of these supervisors could explain who actually performed this critical function.

The facility's own contract with Hospice G, signed January 5, 2025, spelled out exactly what should have happened. Under the hospice's responsibilities, the contract required providing "the most recent Hospice plan of care" and ensuring "each resident's written plan of care includes both the most recent Hospice plan of care and a description of the services furnished by the Facility."

The facility's responsibilities were equally clear: maintain accurate medical records including all required documentation from the hospice "in a designated area/section" and ensure "these forms are not removed."

The contract defined a plan of care as "a written individualized plan of services necessary to meet the patient-specific needs" that "includes all patient care physician orders, and planned interventions for problems identified during patient assessments."

Despite having a detailed contract outlining these responsibilities, the facility had no written policy on hospice coordination. When inspectors requested the facility's hospice policy at 7:01 p.m. on April 10, none was provided.

The coordination failures created a dangerous information gap between the facility and hospice providers. ADON E told inspectors "it was possible the facility or hospice could have information that would be useful for the other and without sharing that information, there could be a delay."

For Resident #14, that delay could have meant continuing to receive continuous oxygen when the hospice had changed the order to as-needed. Or missing medication adjustments. Or failing to implement other comfort measures specified in the updated care plan.

The facility's staff admitted they simply didn't know what they didn't know. The hospice binder sat at the nurses' station, potentially containing updated care plans, but no one checked it regularly or knew who should.

LPN J's hands-off approach to the hospice binder reflected a broader confusion about roles and responsibilities. While she spoke with hospice nurses during visits, she treated their documentation as off-limits rather than as essential information for coordinating care.

The breakdown occurred despite multiple layers of nursing supervision. The facility employed licensed practical nurses, registered nurses, assistant directors of nursing, a director of nursing, and an administrator. Yet when federal inspectors asked who was responsible for hospice coordination, the answer from leadership was consistent: nobody knew.

Resident #14's case illustrated how easily critical information can fall through the cracks when facilities fail to establish clear protocols for hospice coordination. The resident's oxygen needs had changed, but the facility's nursing staff remained unaware of the updated orders except through informal verbal communication.

The hospice nurse continued making her weekly visits and providing verbal updates, but the facility had no system to ensure those updates were properly documented and incorporated into the resident's care plan.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for San Antonio West Nursing and Rehabilitation from 2026-04-10 including all violations, facility responses, and corrective action plans.

Additional Resources

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