Failure to Integrate Hospice Wound Care into Resident Care Plan
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident's care plan was integrated with the hospice plan of care and did not include a care plan addressing the resident's wound care needs. The resident, who was admitted with diagnoses including palliative care and abnormal diagnostic findings, developed a large, tunneling breast mass that required wound care. The resident's representative stated that hospice was providing wound care, and hospice documentation confirmed ongoing wound management. However, there was no corresponding order for wound care or a care plan in the facility's electronic health record. Interviews with facility staff, including an RN, the Unit Manager, and the DON, confirmed that the resident did not have a care plan for wound care provided by hospice, and that such care should have been documented and integrated into the facility's care planning process. The facility's policy required comprehensive, person-centered care plans that incorporate all identified problem areas and professional services, but this was not followed in the resident's case.