Failure to Integrate Hospice Plan of Care into Resident Care Plans
Penalty
Summary
The facility failed to include comprehensive hospice plans of care for two residents who were receiving hospice services. For one resident with diagnoses including hemiplegia, cerebral infarction, diabetes, chronic kidney disease, and hypertension, the care plan only indicated that the resident was on hospice and directed staff to refer to a notebook at the nurses' station for hospice information. The care plan did not provide staff with hospice contact information, details about supplies and medications provided by hospice, or the frequency of hospice staff visits. Interviews with staff confirmed that this information was not included in the care plan and was only available in the hospice notebook, which staff did not routinely reference for daily care tasks. Another resident, with conditions such as severe protein-calorie malnutrition, chronic kidney disease, major depressive disorder, chronic ulcer, anemia, peripheral vascular disease, diabetes, and paraplegia, also had a care plan that lacked specifics regarding hospice services. The care plan noted the resident's terminal prognosis and directed staff to work with the hospice team, but did not specify delegation of hospice staff services, visit frequency, medications, or medical equipment and supplies provided. Staff interviews revealed that while the hospice provider's name was included, other critical details were missing from the care plan and were instead kept in a separate hospice notebook at the nurses' station. The facility's policy required coordination of care planning with the hospice provider, including all services and supplies provided by hospice. However, the care plans for both residents did not integrate this information, and staff relied on separate notebooks for hospice details rather than having this information readily available in the residents' care plans. This practice resulted in incomplete care plans that did not fully outline the hospice services being provided to the residents.