Failure to Obtain Physician Order and Develop Comprehensive Hospice Care Plan
Penalty
Summary
The facility failed to obtain a physician order and develop a comprehensive care plan for hospice services for one resident who was receiving hospice care. Review of the resident's clinical record showed that there was no physician order for hospice care and no comprehensive care plan addressing hospice services or the use of enablers to support the resident's independence during morning care. Staff interviews confirmed that the resident had been receiving hospice services, but there was confusion among staff regarding who was responsible for entering the necessary physician order and care plan. Additionally, the hospice contractor's care plan did not include instructions regarding the use of enablers, and hospice aides did not have access to the facility's electronic care plan. Documentation in the hospice communication binder indicated that the resident had been on hospice since the end of May, and the last documented hospice service was provided in early June. Interviews with facility staff and hospice aides revealed a lack of clarity about the resident's care needs, particularly regarding the use of enablers during morning care. The facility's policies required coordination with the hospice provider and inclusion of the hospice plan of care and physician orders in the resident's written care plan, but these requirements were not met for the resident in question.