Failure to Integrate Hospice Plan of Care with Facility Care Plan
Penalty
Summary
The facility failed to ensure that the hospice plan of care was integrated with the facility care plan for a resident receiving hospice services. The resident, who had severe cognitive impairment and was dependent on staff for activities of daily living, was enrolled in hospice with multiple diagnoses including anemia, hypertension, arthritis, neuropathy, and urinary retention. The facility's care plan noted the resident was on hospice but did not specify what hospice services were being provided or include the hospice plan of care or visit schedule for staff reference. The medical record lacked this essential information, and staff interviews confirmed that the hospice care plan could not be located in the designated binder or within the electronic care plan system. Further review revealed that the hospice nurse described a detailed hospice service plan, including nursing and aide visits, as well as monthly therapy and support services, but this information was not reflected in the facility's documentation. The director of nursing and corporate nurse acknowledged that the hospice care plan was not available as required for staff reference. The facility's agreement with the hospice provider specified that the hospice plan of care should be established, maintained, and accessible, including details on services, frequency, and measurable outcomes, but this was not implemented in practice for the resident in question.