Failure to Ensure Hospice Plan of Care Availability and Coordination
Penalty
Summary
The facility failed to ensure proper collaboration and communication with hospice providers for two residents receiving hospice care. For both residents, the current hospice plan of care was not available to facility staff, despite the facility's policy requiring coordination and documentation of hospice interventions. Interviews with nursing staff, including the RN, Nursing Supervisor, MDS/Infection Preventionist, and DON, revealed inconsistent understanding and execution of processes for obtaining, reviewing, and integrating the hospice plan of care into the facility's records. Staff were either unaware of the location of the hospice plan of care or stated that it was not provided or reviewed, and documentation in the hospice communication binder was limited to team listings and visit logs without substantive care information. One resident had diagnoses including corticobasal degeneration, Alzheimer's disease, and was receiving palliative care. The facility's care plan referenced hospice involvement and directed staff to see the hospice plan of care, but this document was not found in the resident's chart or the hospice binder. Staff interviews confirmed that the hospice plan of care was not reviewed or integrated into the facility's care planning process, and the designated hospice liaison did not review the hospice plan of care. The second resident, with a history of hemorrhagic stroke, quadriplegia, and vascular dementia, was also receiving hospice care. The resident's care plan included interventions to coordinate with hospice and notify them of changes, but the hospice plan of care was not present in the paper chart, electronic medical record, or hospice binder. Facility staff had to request the hospice plan of care from an external electronic health record, indicating a lack of immediate access and integration. The DON confirmed the expectation that the facility should review and align the hospice plan of care with the facility's plan, but this was not occurring.