Failure to Maintain Hospice Plan of Care Documentation
Penalty
Summary
A deficiency was identified when a resident with a terminal prognosis, who was receiving hospice services, did not have a hospice plan of care available in either the paper or electronic medical records. During a review of the resident's records, surveyors were unable to locate the required hospice plan of care or documentation of the communication process related to hospice services. The absence of this documentation was confirmed by the Long-Term Care Unit Manager, who acknowledged that the plan of care should have been present in the resident's health records. Further inquiry revealed that the Director of Nursing was also unable to provide the hospice plan of care at the time of the initial request and was waiting for the necessary documents to be sent from the hospice provider. The lack of a hospice plan of care meant that there was no documented guidance to ensure the resident's needs were being addressed and met as part of their hospice care.