Failure to Coordinate and Document Hospice Services in Care Plan
Penalty
Summary
The facility failed to develop and implement an integrated care plan that clearly coordinated and delineated the responsibilities of hospice and facility staff for a resident receiving hospice care. The resident, who was dependent on staff for all activities of daily living and had multiple diagnoses including dementia, alcohol dependence, and other chronic conditions, was receiving hospice services. However, the facility's care plan did not mention hospice involvement or specify which services were to be provided by hospice versus the facility. The direct care staff Kardex also lacked any reference to hospice services or coordination with hospice staff for tasks such as bathing. Interviews with facility staff revealed that the electronic medical record system's new care plan library limited the ability to personalize care plans, resulting in the omission of hospice information. The assistant director of nursing acknowledged that hospice was not mentioned in the care plan and that communication with hospice could be inconsistent. The hospice provider reported faxing care plans to the facility and leaving information in a binder, but was unsure how the facility handled this information. Facility policy and the hospice agreement required coordinated care planning, but this was not reflected in the resident's documentation.