Failure to Coordinate Hospice Services in Resident Care Plans
Penalty
Summary
The facility failed to ensure a coordinated plan of care for two residents who were receiving hospice services. Both residents had severe cognitive impairments and multiple complex medical diagnoses, including dementia, chronic kidney disease, and end-stage conditions requiring total dependence on staff for activities of daily living. Their care plans indicated they were on hospice and included general comfort measures, but lacked specific directions for staff regarding collaboration with hospice providers, such as contact information, the services and equipment provided by hospice, and the frequency of hospice visits. Interviews with nursing staff and administrative personnel revealed that while hospice information was available in a binder at the nurse's station, this information was not integrated into the facility's care plans. Staff acknowledged that the care plans should match and include all services the residents received, but confirmed that the facility care plans did not contain the necessary details from the hospice plans of care. The facility's own hospice policy required that each resident's written plan of care include both the most recent hospice plan and a description of the services furnished by the facility to maintain the resident's well-being. Observations and record reviews confirmed that the lack of integration and coordination between the facility's care plans and the hospice providers' plans placed the residents at risk for inappropriate end-of-life care. The deficiency was identified through review of medical records, care plans, and interviews with staff, which consistently showed that the required coordination and documentation were not present in the facility's care planning process.