Failure to Document Hospice Service Details in Care Plan
Penalty
Summary
The facility failed to include essential hospice care details in the care plan for a resident with severe cognitive impairment, multiple chronic conditions, and a terminal diagnosis. The care plan documented the hospice provider and contact information but lacked specifics regarding the delegation of hospice staff services, visit frequency, medications, medical equipment, and the preferences of the resident's representative. The resident was admitted to hospice care with a primary diagnosis of senile degeneration of the brain and had significant functional and cognitive impairments, requiring substantial assistance with daily activities and receiving as-needed pain medication. Observations and staff interviews confirmed that hospice services were being provided, with hospice staff visiting twice weekly. However, the care plan did not reflect the necessary details about the hospice services being delivered. Staff also verified that the resident's family preferred the resident not be aware of receiving hospice care. The facility's hospice agreement required a written plan of care that delineates services and reflects the participation of all parties, but this was not adequately documented in the resident's care plan.