Failure to Revise Care Plan for Comfort Measures Only
Penalty
Summary
The facility failed to ensure that the comprehensive care plan for a resident with chronic obstructive pulmonary disease, hypertensive heart disease with heart failure, and chronic pain was reviewed and revised to include interventions related to comfort measures only. After the resident was placed on hospice care due to heart failure and chronic pain, hospice care was later discontinued, and a physician's order directed comfort measures only. However, a review of the clinical record did not identify a care plan with interventions specific to comfort measures. The resident was aware of the comfort measures order but was not sure what specific treatments were in place to maintain comfort. Interviews with facility staff revealed that the MDS director was responsible for reviewing and revising care plans according to the resident's assessment schedule, and the social worker was responsible for care plans related to hospice and comfort measures. The MDS director acknowledged that a terminal diagnosis care plan should have been added and amended to reflect the comfort measures order, but this was not done. Facility policy required that care plans be reviewed and revised following significant changes in status and kept current by all disciplines, but this process was not followed for the resident in question.