Failure to Coordinate Hospice Services in Care Plans
Penalty
Summary
The facility failed to ensure a coordinated plan of care for two residents who were receiving hospice services. For one resident with diagnoses including dementia, Alzheimer's disease, major depressive disorder, and diabetes mellitus, the care plan directed staff to coordinate with hospice and maintain comfort, but did not specify when hospice staff would be present or what care and supplies hospice would provide. The resident's care plan also lacked details on the specific roles and responsibilities of hospice staff in relation to the facility staff. Another resident, with chronic kidney disease, diabetes mellitus, overactive bladder, chronic lymphocytic leukemia, polyarthritis, Crohn's disease, and chronic pain syndrome, had a care plan that instructed staff to coordinate with hospice for comfort and care. However, this care plan also lacked information about the frequency of hospice staff visits, the specific disciplines involved, and the medications and supplies provided by hospice. Interviews with facility staff revealed uncertainty about the frequency of hospice nurse and aide visits, and the care plan did not reflect the actual coordination occurring between the facility and hospice provider. The facility's own hospice policy required that a significant change in status assessment be initiated and the plan of care updated to reflect coordination with hospice services. Despite this, the care plans for both residents did not include essential details about hospice involvement, such as visit schedules and supplies, resulting in a lack of clear coordination between the facility and hospice providers.