The breakdown in communication violated the facility's own agreement with the hospice provider, which required immediate notification when any hospice patient experienced a significant change in condition or needed transfer from the nursing home.
Resident #2 had been readmitted to the facility in August on hospice services after a hospital stay. Her diagnoses included seizures, bone density disorders, anxiety, muscle weakness, and dementia with mood disturbance. The facility's care plan specifically directed nursing staff to notify the hospice provider of any noted changes in the resident's condition.
On November 18 at 10:10 PM, the resident rolled over her bed's side rails and fell to the floor. A certified nursing assistant discovered her bleeding from the nose after hitting the floor face-first. The fall also caused a skin tear above her right eyebrow.
A registered nurse applied pressure to stop the bleeding until paramedics arrived. The facility's incident report documented immediate actions: apply pressure to the nose, notify the physician, notify the family. Hospice notification wasn't mentioned.
The nursing progress note recorded the sequence: "Resident fell off the bed at 10:10 P.M. According to CNA report, resident was in bed when she noticed that resident rolled over the side rails and fell. Resident hit her nose on the floor. Resident was bleeding from the nose. RN applied pressure to the affected area to stop the bleeding until 911 got to the facility."
Emergency contact, risk manager, and physician were all notified. Paramedics transported the resident to the hospital.
Nobody called hospice.
The hospice team manager confirmed during the December 23 inspection that her organization had no record of being notified about the fall or hospital transfer. She stated hospice expected notification of any change in a hospice resident's condition.
The facility's Director of Nursing acknowledged the failure during the same inspection. She stated the hospice provider should have been informed of the fall and transfer, and that such notification should have been documented in the medical record. The DON said she wasn't working at the facility when the incident occurred and wasn't aware hospice had never been notified.
The oversight violated the facility's own service agreement with the hospice provider, signed January 1, 2019. The contract explicitly required the nursing facility to "notify Hospice when the Hospice Patient experiences a change of condition" and to "notify the Hospice Patient's attending physician and family of significant change in condition."
The agreement went further, requiring the nursing facility to "immediately notify hospice if a significant change in a hospice patient's physical, mental, or emotional status occurs including the need to transfer a hospice patient from the nursing facility."
A fall resulting in facial bleeding and emergency hospitalization clearly qualified as a significant change requiring immediate hospice notification.
The resident's comprehensive care plan, initiated when she began hospice services in August and revised in November, included specific approaches for monitoring hospice patients. Staff were directed to observe daily for pain medication effectiveness, nausea, appetite changes, mobility issues, and communication difficulties.
When changes were noted, the care plan required notification of "the nurse, physician, and hospice provider."
The facility followed part of this protocol after the November fall — they notified the nurse, physician, family, and risk manager. But they omitted the hospice provider, breaking both their care plan directive and contractual obligation.
Federal inspectors found the communication breakdown represented a failure to ensure collaboration between the facility and hospice provider in delivering necessary care and services. The violation affected one of 12 residents reviewed during the inspection, but highlighted gaps in the facility's hospice coordination procedures.
The resident had been living with multiple complex conditions including dementia, making effective communication between her care providers essential for managing her end-of-life needs. When she experienced a traumatic fall requiring emergency intervention, that communication failed at a critical moment.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Terrace of Kissimmee, The from 2025-12-23 including all violations, facility responses, and corrective action plans.