Failure to Include Hospice Services in Resident Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for three residents who were receiving hospice services. Record reviews revealed that these residents had significant medical conditions, including various forms of dementia, heart failure, and schizoaffective disorder, and had been admitted to hospice care as ordered by their physicians. Despite these admissions, their care plans did not include focus areas or interventions related to hospice services, and in some cases, progress notes did not reflect hospice involvement. For one resident, the care plan was last reviewed after the initiation of hospice services but did not address hospice care needs. Another resident's care plan included interventions for mood problems and overall decline but did not specifically address the terminal diagnosis or hospice admission, even though physician orders and MDS assessments indicated hospice care was in place. The third resident's care plan, initiated prior to hospice admission, was not updated to reflect the new hospice status, despite documentation in progress notes and physician orders confirming hospice enrollment. Interviews with facility leadership, including the DON and Administrator, confirmed that hospice services should have been included in the care plans and that care plan meetings with hospice were standard practice. The DON acknowledged the omission and was unaware of how these residents were missed. The facility's own policy requires comprehensive, person-centered care plans with measurable objectives and timetables, developed by the interdisciplinary team and revised as residents' conditions change, which was not followed in these cases.