Failure to Develop and Implement Hospice Care Plan Upon Admission
Penalty
Summary
A deficiency was identified when a resident admitted from a hospital with Hospice care in place did not have a comprehensive, patient-centered Hospice care plan developed or implemented upon admission. The facility's policies require the interdisciplinary team to create and regularly update a care plan that includes collaboration with Hospice, the resident, and family. However, review of the resident's electronic medical record revealed no Hospice orders, no progress notes from medical providers indicating collaboration with Hospice, and no care plans addressing Hospice services. Despite documentation from the hospital and Hospice provider confirming the resident was receiving Hospice care, this information was not reflected in the facility's care planning documentation. Interviews with facility staff and the Hospice provider confirmed that Hospice services were being provided, including nursing, aide, and social work visits. However, communication breakdowns were evident, as the admissions process failed to relay the Hospice status to the care team, and staff were unaware or unable to document the resident's Hospice care in the system. The Director of Social Work stated they could not update the care plan without being informed of the resident's Hospice status, and the Nurse Liaison acknowledged that the information was not communicated as required. This lack of coordination and documentation resulted in the absence of a comprehensive Hospice care plan for the resident.