Failure to Coordinate Facility and Hospice Care in Resident Care Plan
Penalty
Summary
The deficiency involves the facility’s failure to ensure coordinated care and services between the facility and hospice for a resident receiving hospice services. The resident had diagnoses including dementia, metabolic encephalopathy, DM, atrial fibrillation, and chronic pain, and a Significant Change MDS showed a BIMS score of eleven, indicating moderately impaired cognition. The MDS documented that the resident required extensive staff assistance with toilet hygiene and supervision with oral hygiene, personal hygiene, and other ADLs, and that the resident was receiving hospice services. The ADL care plan noted a decline in the resident’s ability to care for herself after a fall in assisted living, with increased confusion, several falls, and increased need for staff assistance with most ADLs. Despite the resident’s admission to hospice on 11/14/25 with a diagnosis of senile degeneration of the brain, review of the clinical record showed that the facility’s care plan did not contain any information indicating that the resident was on hospice services. On observation, the resident was seen dressed in street clothes and eating breakfast at the dining room table. During an interview, an administrative nurse confirmed that the facility care plan lacked any indication that the resident was receiving hospice services and verified that the resident had been on hospice since 11/14/25. The facility’s End of Life policy stated that end-of-life care, including hospice, should be provided through an interdisciplinary approach with a care plan developed by the team to address actual and potential problems, but this coordination with hospice was not reflected in the resident’s care plan.
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