Failure to Update Hospice Care Plans and Ensure Accessible Documentation
Penalty
Summary
The facility failed to ensure that hospice services provided to two residents met professional standards and principles, specifically in the areas of care plan updates and documentation accessibility. For one resident with chronic obstructive pulmonary disease (COPD) and other comorbidities, the care plan was not updated to reflect the initiation of hospice services. The care plan lacked delineation of responsibilities between the facility and the hospice provider, and staff interviews revealed a lack of awareness regarding the resident's hospice care goals and the location of hospice documentation. Despite staff knowing the resident was on hospice, the comprehensive care plan did not include hospice interventions or coordination details. For another resident with dementia and other diagnoses, the facility did not ensure that hospice agency notes regarding care were easily accessible to facility staff. Although the resident was admitted to hospice services, the hospice binder and electronic medical record (EMR) did not contain documentation from hospice nursing staff about their visits and care provided, except for a single social worker visit. Staff reported that hospice staff verbally communicated care provided, but there was no written documentation in the resident's records. The lack of accessible documentation hindered effective coordination of care between the facility and hospice agency. Facility policy required that a care plan be developed upon admission to hospice and that hospice services be integrated into the individualized, interdisciplinary care plan. The contract with the hospice provider also stipulated the need for communication and documentation in the resident's medical chart. However, these requirements were not met, as evidenced by the absence of updated care plans and accessible hospice documentation for the residents reviewed.