Failure to Integrate Hospice Services Into Resident Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate collaboration with hospice providers and to incorporate hospice services into the residents’ care plans. One resident with dementia, depression, anxiety, and severely impaired cognition had documentation in the EMR and MDS indicating she was receiving hospice services, with a nursing note confirming hospice admission. Her care plan referenced consulting with the physician and social services to have hospice care in the facility and included comfort-focused interventions such as oxygen for comfort and pain management. However, the care plan did not clearly outline the specific hospice services being provided, despite her documented hospice status. Another resident with dementia, major depressive disorder, anxiety, bipolar disorder, and severely impaired cognition had an order for hospice of the family’s choice to evaluate and treat and was confirmed by nursing staff to have been admitted to hospice. The care plan for this resident only documented that hospice would provide extra bathing on two specified days and lacked other hospice services. Staff interviews revealed that information about hospice services was kept in a separate hospice-provided book and that not all hospice services were included in residents’ care plans. An administrative nurse acknowledged that the facility only included some, but not all, hospice services on the care plans, contrary to the facility’s hospice program policy that addressed services to be provided and coordination of care.
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