Failure to Maintain Current Hospice Plan of Care in Clinical Record
Penalty
Summary
Facility staff failed to ensure that the written plan of care for a resident included both the most recent hospice plan of care and a description of hospice services, as required. The resident, who was admitted under hospice care from another LTC facility, had diagnoses including malignant ovarian and endometrial cancer, a right nephrostomy tube due to hydronephrosis with ureteral stricture, and bilateral lower extremity lymphedema. The resident was cognitively intact but dependent on staff for most self-care activities. Despite a physician's order to admit the resident to hospice care, the clinical record did not contain the hospice agency's plan of care at the time of review. Staff interviews confirmed that the hospice care plan was not present in the clinical record, and the Assistant Director of Nursing indicated it may not have been uploaded by Medical Records. A hospice document was later added to the record, but it only covered a previous benefit period and did not address the current period. The absence of the current hospice plan of care in the resident's clinical record constituted the deficiency identified by surveyors.