Failure to Include Hospice Services in Initial Care Plan
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan addressing hospice services for a resident admitted with hypertensive heart disease and congestive heart failure. Upon admission, the resident was receiving hospice services, as documented in the electronic health record. However, the initial care plan did not include hospice care, and the admission Minimum Data Set (MDS) did not reflect the resident's hospice status. The hospice care plan was not added until a later date, despite the resident's ongoing need for hospice services. Interviews with facility staff, including the Nurse Practitioner, MDS Supervisor, Director of Nursing, and Administrator, confirmed that hospice services should have been included in the initial care plan. The MDS Supervisor acknowledged the omission and emphasized the importance of accurate, person-centered care plans. The deficiency was identified through record reviews and staff interviews, which revealed the delay in incorporating hospice care into the resident's care plan.