Lack of Comprehensive Hospice Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident receiving hospice services. The resident, who had both long-term and short-term memory impairment, exhibited hallucinations and rejection of care behaviors, and was identified as being at the end stage of life and receiving hospice or palliative care. The care plan in place was generic, listing interventions such as calling hospice for new physician orders and coordinating with hospice, but lacked specific details regarding the frequency and nature of hospice services to be provided. References in the care plan directed staff to a hospice binder at the nursing station for further information, but this binder only contained general documents such as a POLST, emergency contact information, and summary notes from hospice staff visits, without a detailed or individualized hospice care plan. Interviews with facility staff and hospice personnel revealed that the hospice care plan was maintained in the hospice agency's electronic record system, which was not accessible to facility staff, and a printed copy was not available in the resident's binder. Staff were unclear about the specifics of hospice services being provided, with one LPN unable to recall seeing a hospice aide or a care plan in the binder, and the hospice nurse confirming that the care plan was not shared with the facility. The assistant director of nursing verified that the facility's care plan was generic and that the hospice care plan was not provided prior to the survey, resulting in a lack of a comprehensive, accessible care plan to promote continuity of care for the resident.