Lack of Coordinated Hospice Care Plan in Medical Record
Penalty
Summary
The facility failed to ensure that a current hospice care plan was present in the medical record and coordinated with facility staff for one resident. According to facility policy, when a resident is enrolled in hospice, a coordinated plan of care must be developed between the facility, hospice agency, and resident/family, and this plan should include directives for managing pain and other symptoms. The policy also requires that the hospice agency retains professional management responsibility and that both the facility and hospice identify and communicate the specific services each will provide in the plan of care. A resident admitted with a stage 4 sacral pressure ulcer and moderate cognitive impairment was receiving hospice services, as indicated by the MDS assessment and a physician's order. While the facility care plan noted the resident was receiving hospice care, the hospice agency's plan of care was not available in the medical record for staff review. During interviews, a nurse stated that all hospice communication was uploaded in the electronic medical record, but the DON confirmed that the hospice plan of care had not been sent over and was not accessible to staff.