Failure to Maintain Appropriate Hospice Diagnosis and Plan of Care Documentation
Penalty
Summary
Surveyors identified that the facility failed to ensure hospice services met professional standards for one resident receiving hospice care. The resident had a medical history that included Alzheimer's disease, dementia, epilepsy, and Down syndrome, and was originally admitted to the facility on one date and re-admitted on another. Record review of the hospice admission order form showed the resident was admitted to hospice with a diagnosis of Down syndrome listed as the hospice diagnosis. During interview, the DON confirmed that this diagnosis did not meet her expectations as a qualifying diagnosis for hospice care. Further review of the resident's EHR revealed that the hospice plan of care was not available in the facility's records, and the DON confirmed the facility did not have a record of the resident's hospice plan of care. These findings show that the facility did not ensure the resident had an appropriate qualifying hospice diagnosis documented and did not maintain the hospice plan of care in the resident’s record while the resident was receiving hospice services.
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