Failure to Align Hospice Care Plan with Ordered Diagnoses
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan that addressed all of a resident's needs, specifically omitting a focus area and interventions for the resident's ordered hospice care diagnosis. Record review showed that a female resident with severe cognitive impairment and multiple diagnoses, including senile degeneration of the brain and cerebral atherosclerosis, was admitted to hospice care. However, the care plan only included senile degeneration of the brain as the hospice diagnosis, while the hospice order also listed cerebral atherosclerosis. This discrepancy was identified during a review of the resident's records and confirmed by the Director of Nursing (DON), who acknowledged that the care planned diagnosis should match the medical diagnoses and orders. The DON stated that the facility's process is to include the diagnosis from the order in the care plan, and upon review, recognized that the hospice order diagnosis did not match the care planned diagnosis for the resident. The facility's policy requires the comprehensive care plan to describe the services needed to attain or maintain the resident's highest practicable well-being, but in this case, the care plan did not reflect all relevant hospice diagnoses as ordered. This failure was identified through observation, interview, and record review, and was acknowledged by facility leadership as not meeting expectations for care planning.