Failure to Coordinate Hospice Services in Resident Care Plan
Penalty
Summary
The facility failed to ensure coordinated care and services between the facility and hospice for a resident receiving end-of-life care. The resident, who had diagnoses including dementia, osteoporosis, muscle weakness, and sarcopenia, was documented as requiring extensive staff assistance with activities of daily living and had bilateral lower extremity contractures. The resident's care plan noted the need for monitoring skin breakdown and immobility, and the hospice care plan indicated the provision of comfort measures and medication administration. However, the facility's care plan lacked specific instructions regarding the coordination with hospice, such as the frequency and type of hospice support visits, supplies and medical equipment provided by hospice, medications covered by hospice, and hospice contact information. Record review and staff interview confirmed that the facility did not include detailed information from the hospice plan of care in the resident's facility care plan. The facility's own policy required identification in writing of the services hospice would provide and for these to be addressed in the resident's person-centered care plan. Despite this, the care plan did not reflect the necessary coordination, and the administrative nurse verified the absence of this information.