Missing Hospice Plan of Care in Resident Record
Penalty
Summary
The facility failed to ensure that a current hospice plan of care was present in the medical record and coordinated with facility staff for one resident. The resident, who had a diagnosis of cerebrovascular disease and severe cognitive impairment, was admitted to hospice care per a physician's order. Although the facility's care plan indicated the need for hospice services due to an end-stage disease process, the hospice agency's plan of care was not available in the resident's medical record for staff reference. Interviews with facility staff revealed uncertainty regarding the timeline for receiving the hospice plan of care. The DON stated that the plan is usually provided right away but could not specify an exact timeframe, while the social worker was unaware of how soon the hospice should provide the plan. The facility's policy requires a written agreement and coordination with the hospice provider, but documentation of the hospice plan of care was missing from the resident's record at the time of review.