Failure to Coordinate Hospice and Facility Care Plans
Penalty
Summary
The facility failed to ensure a coordinated plan of care between the facility and hospice services for a resident who was admitted to hospice. The resident had multiple diagnoses, including fibromyalgia, hypertension, peripheral vascular disease, major depressive disorder, diabetes mellitus, muscle weakness, and senile degeneration of the brain, and required significant assistance with activities of daily living. The resident's care plan documented admission to hospice and outlined comfort measures, maintenance of dignity, and the provision of supplies by hospice. However, review of records and staff interviews revealed that information regarding hospice services, such as supplies provided and the schedule of hospice staff, was not consistently included in the facility's care plan. Instead, this information was maintained separately in a hospice binder at the nurse's station, and staff relied on verbal communication and the binder for updates. Certified Nursing Aides and Licensed Nurses reported that they did not believe hospice information was integrated into the facility's care plan, and the Administrator confirmed that while communication with hospice was good, the care plans between the facility and hospice should match. The facility's policy required individualized, interdisciplinary plans to address residents' needs, but the lack of a unified, coordinated care plan placed the resident at risk for inappropriate end-of-life care. The deficiency was identified through observation, record review, and staff interviews, which demonstrated a failure to develop and maintain a coordinated plan of care as required.