Failure to Conduct Care Planning Review After Significant Change for Hospice Resident
Penalty
Summary
The facility failed to conduct a care planning review in coordination with a significant change Minimum Data Set (MDS) assessment for a resident who was receiving hospice care. The resident, who had multiple diagnoses including palliative care needs, severe cognitive impairment, and memory loss, was admitted, hospitalized, readmitted, and then signed onto hospice services. Despite the completion of a significant change MDS assessment, there was no documentation of a care planning review involving the resident, their legal representative, the interdisciplinary team, or hospice staff after the resident began hospice care. The only documented care conference occurred shortly after admission, with no subsequent reviews noted in the clinical record following the significant change in the resident's condition. Interviews with facility staff confirmed that a care planning review had not been completed as required. The Social Work Director acknowledged responsibility for coordinating the care conference but admitted it had not yet been done. Additionally, the hospice nurse reported not being involved in any care planning review with the resident, legal representative, or facility staff after the resident started hospice care. The facility's own policy requires care conferences to be offered on admission, quarterly, with significant changes in condition, and upon request, but this was not followed in this case.