Failure to Update Care Plans for Code Status and Hospice Services
Penalty
Summary
The facility failed to revise and update the care plan for two residents as required. For one resident with diagnoses including diabetes and chronic lung disease, the Minimum Data Set (MDS) assessment documented that the resident was cognitively intact and had a life expectancy of less than six months, and was receiving Hospice services. Despite a physician order changing the resident's code status from full code to Do Not Resuscitate (DNR), the care plan continued to reflect the previous full code status and did not address the new DNR order. Additionally, after a physician order for a Hospice referral and subsequent admission to Hospice, there was no care plan in place addressing Hospice services for the resident. Interviews with the MDS nurse and the DON revealed that care plans were expected to be reviewed and updated daily during clinical care meetings with the interdisciplinary team. However, both staff members acknowledged that the care plan for this resident had not been updated to reflect the changes in code status or the initiation of Hospice services. The DON was not aware of the omissions until the time of the interview, despite regular care plan reviews being part of the facility's process.