Failure to Integrate Hospice Services Into Resident Care Plans
Penalty
Summary
Surveyors identified a deficiency in the facility’s coordination and documentation of hospice services for two residents receiving end-of-life care. For one resident, the EMR contained a physician’s order for a hospice referral dated 01/06/26 but lacked an order to admit the resident to hospice services. The resident’s care plan, dated 01/07/26, included general directions to adjust ADLs, encourage participation, consult with physicians and Social Services for hospice care, and work cooperatively with the hospice team to meet the resident’s needs and provide maximum comfort. However, the care plan did not specify the hospice provider’s contact information, the services hospice would provide, the supplies, equipment, and medications hospice would furnish, or the frequency of hospice staff visits. During observation on 02/23/26, the resident was seen in a high-back wheelchair in his room with a soft-touch call light nearby and a fall mat folded and leaning against the wall. For the second resident, the EMR showed a physician’s order dated 10/15/25, and the care plan revised on 02/02/26 indicated the resident was on end-of-life support, with directions to participate in activities as tolerated, assist with ADLs such as ambulation and mobility, and keep the resident as comfortable as possible. This care plan also lacked specific directions regarding the hospice provider’s services, including what supplies, equipment, and medications hospice would provide and how often hospice staff would visit. A CNA reported that nurses typically informed aides which residents were on hospice and which days the hospice aide would provide showers, but could not identify what supplies and equipment hospice provided. An LN stated that each hospice resident had a separate hospice book containing the hospice plan of care, including medications, supplies, equipment, and visit schedules, and did not believe this information needed to be in the resident’s person-centered plan. The Administrative Nurse confirmed that she expected this information to be in the resident’s plan of care, acknowledged that hospice orders for one resident were likely only in the hospice binder, and stated that hospice information was not entered into the EMR until after the resident died or the hospice episode ended, despite facility policy requiring an interdisciplinary, individualized plan based on comprehensive assessment and hospice appropriateness.
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