Missing Hospice Plan of Care in Medical Record
Penalty
Summary
The facility failed to ensure that a coordinated plan of care with the hospice provider was available in the medical record for one resident receiving hospice services. Review of facility policy and the hospice contract indicated that a written, coordinated plan of care should be developed and maintained jointly by the facility and the hospice provider, and that this plan should be present in the resident's medical record. However, upon review of the medical record for a resident admitted with traumatic subdural hemorrhage and dementia, there was no hospice provider's plan of care present. The comprehensive care plan referenced the need to develop a coordinated care plan, but the actual hospice plan of care was missing from the record. Interviews with facility staff, including an RN, the DON, and an LPN Unit Manager, revealed that they were unaware of how to locate the hospice provider's plan of care in the medical record. The LPN Unit Manager confirmed that hospice documentation was in the computer chart but acknowledged that the hospice provider's plan of care was not included in the resident's medical record. The DON also confirmed that the hospice provider's plan of care was supposed to be available in the medical record. Observation of the resident showed the individual was comfortable and without concerns at the time.