The Hospice Case Manager told federal inspectors on October 6 that she recognized facility nurses by their faces but never documented their names when she visited Resident 8. She couldn't provide evidence that another case manager had visited the resident on October 3, despite claims that the visit occurred.
"If it was not documented, it was not completed," the Hospice Case Manager told inspectors, explaining her own company's policy.
The inspection revealed a breakdown in the tracking system designed to ensure terminally ill residents receive the specialized care they need in their final days. Hospice workers were supposed to sign into a binder after each visit and document their activities in communication notes. Multiple visits appeared to be missing from the records.
The Hospice Patient Care Manager explained that all hospice disciplines — skilled nurses, aides, social workers, chaplains and physicians — must sign into the facility and the hospice binder to track care delivery. Each resident had their own binder containing a sign-in sheet and staff communication notes that workers were required to complete after every visit.
"All the hospice disciplines were informed and oriented they must sign in the hospice binder with every visit," the Patient Care Manager said. He told inspectors that Hospice Case Managers were responsible for checking the binders weekly to verify that all scheduled visits had occurred.
But he wasn't aware of the missing visits and documentation failures for Resident 8.
The facility's Director of Nursing acknowledged that she expected all hospice workers to sign in during every visit. She said charge nurses assigned to hospice residents were supposed to document when hospice nurses and aides came to provide care.
"The RN and LVNs assigned to the hospice residents were responsible for checking if each hospice resident had received the scheduled visits from the hospice disciplines," the DON explained. This verification was supposed to be documented in each resident's hospice binder under the sign-in sheet or staff communication notes.
She emphasized the importance of the sign-in process: "It was important for each hospice discipline to sign in the hospice binder to show hospice services were provided to the hospice residents."
The DON outlined the facility's protocol for addressing missing visits. If charge nurses discovered gaps in hospice care while checking the binders, they were supposed to notify social services staff, who would follow up with the hospice company during care conferences.
When asked about the impact of missing hospice visits, the DON suggested the clinical consequences might be limited. She said hospice services not coming to the facility "would not have made any difference" for the residents' medical outcomes.
However, she acknowledged that "the 1:1 support from hospice care would be missing."
That one-on-one support represents a crucial component of end-of-life care. Hospice workers provide specialized pain management, emotional support, and comfort measures that facility staff may not be trained to deliver. They also serve as advocates for residents and their families during one of the most difficult periods of their lives.
The inspection findings suggest a systemic failure in communication between the hospice provider and the nursing home. The Hospice Case Manager's inability to remember or document facility nurses' names points to a lack of meaningful coordination between the two care teams.
This coordination is essential because hospice residents often require complex care that involves both facility staff and specialized hospice workers. Without proper documentation and communication, residents may miss critical services or receive duplicated care.
The missing documentation also makes it impossible to verify whether residents received the full scope of hospice services they were entitled to receive. Families who choose hospice care for their loved ones expect comprehensive support that includes not just medical care, but also spiritual, emotional, and social services.
The DON and Administrator were informed of the inspection findings on October 7 and acknowledged the violations. The facility now faces the challenge of implementing systems to ensure hospice workers properly document their visits and coordinate effectively with nursing home staff.
For families with loved ones in hospice care at nursing facilities, these findings raise important questions about oversight and accountability. When multiple organizations share responsibility for a resident's care, clear documentation becomes the only way to verify that promised services are actually being delivered.
The inspection occurred in response to a complaint, suggesting that someone — possibly a family member or staff member — had concerns about the quality of hospice care being provided at the facility.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Pelican Ridge Post Acute from 2025-10-06 including all violations, facility responses, and corrective action plans.