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F0684
D

Failure to Ensure Collaborative Hospice Care and Updated Care Plans

San Rafael, California Survey Completed on 08-21-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure collaborative care with the contracted hospice agency for a resident who was admitted with a dislocated internal left hip prosthesis and Huntington's disease. During an observation and interview, the hospice registered nurse case manager was found without the necessary wound care orders and had not updated the hospice binder with the resident's wound care plans. The director of nursing confirmed that there were no wound orders or care plans for the resident in the hospice binder, which was an oversight and impacted the resident's comfort of care. Further review of facility policies and the hospice contract revealed that hospice providers are required to maintain updated and coordinated care plans, including the most recent hospice plan of care and all relevant physician orders. The facility is responsible for ensuring collaboration and that the hospice agency's nursing care plan is included in the resident's record. In this case, the lack of updated documentation and care plans in the hospice binder led to a breakdown in communication and coordination of care for the resident.

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