Failure to Coordinate and Document Hospice Care Plans
Penalty
Summary
The facility failed to coordinate and document a plan of care with the Hospice provider for two residents who had elected Hospice services. Both residents had significant cognitive impairments and multiple medical diagnoses, including dementia, malnutrition, and chronic pain. Although the residents' responsible parties had signed the Election of Hospice Benefit forms and Hospice care was indicated in their Minimum Data Set (MDS) assessments, the facility's care plans did not reflect that the residents were receiving Hospice services. Review of the electronic care plan records showed no current Hospice plan of care, only progress notes from Hospice. Interviews with the Director of Nursing (DON), MDS nurses, Clinical Compliance Administrator, and the Hospice Nurse confirmed that the facility's care plans were not updated to include Hospice interventions or documentation. The DON acknowledged that the process for obtaining and coordinating a Hospice care plan was not followed, and that the MDS nurses had overlooked updating the care plans. The Hospice Nurse stated that she provided all necessary documentation to the facility, but was unaware that the care plans had not been updated. Both the DON and Administrator confirmed that Hospice information should have been included in the facility's care plans for these residents, but it was not.