Failure to Integrate Hospice Plan of Care with Facility Care Plan
Penalty
Summary
The facility failed to ensure that the hospice plan of care was integrated with the facility care plan for a resident receiving hospice services. The resident, who had impaired cognition and multiple complex medical diagnoses including cancer, atrial fibrillation, hypertension, arthritis, dementia, anxiety, depression, and chronic pain, required assistance with activities of daily living. The care plan indicated the need for communication and coordination with hospice, including maintaining contact, informing hospice of changes in condition, and involving hospice in care conferences. However, upon review, the hospice plan of care was not found in the resident's medical record, and only hospice encounter notes were present. Staff were unaware of the hospice visit schedule, and documentation of hospice visits was incomplete, with missing entries for several months. Interviews with facility staff revealed a lack of awareness regarding the frequency and scheduling of hospice visits, as well as the location of the hospice care plan in the medical record. The director of nursing confirmed that the hospice care plan was not available for review, and the social worker stated that hospice was invited to care conferences but did not have information on visit schedules. The facility's agreement with the hospice provider required coordination and periodic review of the hospice plan of care, but this was not demonstrated in practice, leading to a deficiency in integrating hospice services with the facility's care planning process.