Failure to Develop Comprehensive Hospice Care Plan
Penalty
Summary
The facility failed to develop an individualized and comprehensive hospice plan of care for a resident who was admitted with diagnoses including cirrhosis, hepatic encephalopathy, and congestive heart failure. The resident was admitted to hospice care upon entry to the facility, as indicated in the Order Summary Report. However, upon review of both the hospice medical record and the facility's electronic medical record, it was found that no hospice care plan had been developed or initiated by either the hospice provider or the facility. Interviews with the Social Services Director and the Director of Nursing confirmed that a coordinated hospice care plan should have been created upon admission to address the resident's specific needs, goals, and interventions. The facility's policy and procedures also require collaboration between facility staff and the hospice agency to establish a care plan based on the resident's assessment. Despite these requirements, the necessary hospice care plan was not in place for the resident.