Failure to Timely Revise Care Plans for Changes in Hospice, Comfort Care, and Medication
Penalty
Summary
The facility failed to ensure that care plans were revised in a timely and accurate manner to reflect significant changes in residents' care, including discontinuation of hospice services, initiation of comfort care, and discontinuation of medication. For one resident, the care plan continued to indicate enrollment in hospice for end-of-life care even after hospice services had been discontinued, as confirmed by both nursing staff and the DON. Another resident's care plan inaccurately stated that the resident was receiving a low dose of antidepressant medication, despite the medication having been discontinued and no current physician order for it. Staff interviews confirmed that the care plan had not been updated to reflect this change. Additionally, a third resident who had transitioned to an end-of-life comfort care program did not have this change reflected in their care plan. Staff interviews and record reviews confirmed that the care plan lacked documentation of comfort care or end-of-life goals and treatments. In each case, staff acknowledged that the care plans should have been updated promptly to reflect the residents' current status and care needs, but this was not done.