Failure to Develop Individualized Hospice Care Plan
Penalty
Summary
A review of the clinical record for one resident revealed that the facility failed to develop a care plan addressing the resident's identified need for hospice care. The resident was admitted to hospice and had a significant change Minimum Data Set (MDS) assessment documenting a poor prognosis and receipt of hospice services. Despite this, the resident's care plans did not include an individualized hospice care plan with specific objectives, goals, or timeframes. This omission was confirmed during interviews with the Director of Nursing and other facility staff, and the findings were discussed during the exit conference. The deficiency was identified through both record review and staff interviews, which confirmed that the care plan for activities of daily living (ADLs) was reviewed but lacked the necessary components to address the resident's hospice needs.