Failure to Develop Hospice Care Plan for Resident
Penalty
Summary
The facility failed to ensure a person-centered comprehensive care plan was developed and implemented for a resident who was reviewed for hospice care. The resident, who was admitted with diagnoses including dysphagia, cerebral aneurysm, and dementia without behaviors, had a significant change in their condition as documented in the Minimum Data Set, indicating severely impaired cognition. Despite the resident being accepted onto hospice care effective January 15, 2025, there was no documented evidence of a care plan being developed. The Registered Nurse Supervisor acknowledged the oversight, attributing it to their absence from the facility and recent return to work.
Plan Of Correction
Plan of Correction: Approved March 10, 2025 1. The specific description of the action/activities to be taken in order to achieve correction for the residents found to have been affected by the deficient practice is: At (NAME) Neuman, all residents on hospice care a Terminally Ill care plan is generated, and in the care plan it is indicated resident is on hospice care. Care plan states resident was on hospice dated 01/15/25 with listed interventions for terminally ill care. Registered nurses will be in-serviced to update care plan to reflect services provided to residents on hospice care. In-service on care planning will also be provided to all clinical staff and continue on annual basis to ensure compliance. This training will be extended to all clinical new hires including contract staff. 2. How will The New Jewish Home (NAME) Neuman identify other residents having the potential to be affected by the same deficient practice (and implementation of action as in #1 above)? All residents admitted to the hospice program have the potential to be affected by this deficient practice. The Director of Social Work will generate a list of all residents on the hospice program and this list will be to update the care plans of the residents on the hospice program. 3. What measures will be put into place or systemic changes made to ensure the deficient practice will not recur? Policy of Comprehensive Care Plans was reviewed and was found to be in compliance. An audit tool will be utilized to validate compliance with hospice care planning. The IDT team was educated on the need to develop a comprehensive care plan and implement for all residents on Hospice. 4. How will The New Jewish Home (NAME) Neuman monitor its corrective action to ensure the deficient practice being corrected will not recur (i.e. - what program will monitor the continued effectiveness of the systemic change)? Director of Nursing or Designee will conduct audits 1 X week for one month and 1 X month X three Months. Data collected from the audit process will be reported to the QAPI committee monthly for three months for action appropriate.