Failure to Develop Hospice Care Plan for Resident
Penalty
Summary
The facility failed to develop a person-centered care plan for a resident who was receiving Hospice care, resulting in a deficiency. The resident, identified as Resident #58, was admitted with diagnoses including dementia and Alzheimer's disease and had a severely impaired cognitive status. A significant change in the resident's condition was noted, leading to the initiation of Hospice care. However, upon review, it was found that there was no Hospice care plan developed for the resident, which is a requirement for individualized care. During an interview, the MDS nurse revealed a misunderstanding regarding the responsibility for completing the Hospice care plan. The nurse initially believed that the Social Worker was responsible for this task, but later acknowledged that it was her responsibility. The facility's Care Planning and Coordination Policy mandates that each patient must have an individualized written plan of care, which was not adhered to in this case, leading to the potential for unmet care needs for the resident.
Plan Of Correction
Element #1 Residents #58 no longer resides in the facility. Element #2 Residents residing in the facility have the potential to be affected. Resident care plans have been reviewed and updated to reflect current care needs. Element #3 The interdisciplinary team has been re-educated on the Care Planning and Coordination policy. Element #4 Under the direction of the Quality Assurance Performance Improvement (QAPI) Committee, the Director of Nursing or designee(s) will conduct weekly audits of care plans to ensure appropriateness. The QAPI Committee will review findings monthly and determine ongoing need for audits. Element #5 The Administrator is responsible for sustained compliance.