Failure to Coordinate Hospice Care in Resident's Plan of Care
Penalty
Summary
The facility failed to ensure that a resident's plan of care was properly coordinated with hospice services. Upon review of the resident's medical record and interviews with the DON, it was found that when the resident began hospice care, no interdisciplinary team (IDT) conference was held at the start of hospice, as required. The first IDT conference that did occur included dietary, activities, social services, a hospice nurse, and the resident's representative, but did not include a facility nurse. Additionally, only two of the resident's care plans were updated to reflect the initiation of hospice care, rather than a comprehensive update as expected. Facility policies require that a coordinated plan of care be developed and maintained between the facility, hospice agency, and the resident or their family, with updates as necessary to reflect the resident's current status. The care planning process is intended to be interdisciplinary, involving multiple disciplines including the resident's physician and a facility nurse. The failure to hold a timely and fully staffed IDT conference and to comprehensively update the care plans resulted in a lack of proper coordination for the resident's hospice care needs.