Failure to Update Care Plan After Discharge from Hospice
Penalty
Summary
The facility failed to ensure that a comprehensive care plan was reviewed and revised by the interdisciplinary team after a significant change in a resident's status. Specifically, a resident with multiple diagnoses, including Alzheimer's disease, dementia, hypertension, osteoarthritis, anxiety disorder, COPD, bipolar disorder, muscle weakness, and abnormal posture, was discharged from hospice services after being deemed medically stable. Despite this change, the resident's care plan continued to reflect hospice care and was not updated to reflect the discharge and the initiation of therapy services. Interviews with facility staff revealed that the MDS nurse was unaware of the resident's discharge from hospice until the week of the survey and had not updated the care plan accordingly. The interim DON confirmed that care plans should accurately reflect the resident's current condition. The facility's policy referenced the RAI manual for care plan accuracy, but no specific care plan policy was provided during the survey.