Failure to Maintain Accessible Hospice-Coordinated Plan of Care
Penalty
Summary
The deficiency involves the facility’s failure to have a hospice-coordinated plan of care readily available and integrated into the resident’s record for a hospice-enrolled resident. The resident, admitted after an acute hospital stay, had diagnoses including atrial fibrillation and chronic venous insufficiency, and a significant change MDS showed a BIMS score of 3/15, indicating severely impaired cognitive abilities for daily decision-making. The resident’s care plan, dated 2/4/26, documented admission to hospice services for end-of-life care related to senile degeneration of the brain, with a goal to receive uninterrupted supportive services. Interventions listed included coordinating all of the resident’s needs, communicating changes to hospice, and educating the resident, family, responsible party, and caregivers about changing needs and additional hospice services. Despite this, staff interviews and record review showed that hospice services and coordination were not clearly documented or accessible in the facility. A CNA reported never seeing a hospice aide provide services to the resident and only observing a male nurse visiting approximately twice per week. When interviewed, the DON stated that hospice admission paperwork, the care plan, and visit notes were likely in the resident’s paper chart, but a review of the paper charts revealed no hospice documents. As a result, information about what hospice services would be provided, when and how they would be provided, the communication process, and when or why facility staff should contact hospice was not available in the facility at the time of review. Hospice documents confirming the resident’s hospice admission for senile degeneration of the brain were only produced later, after being faxed to the facility, and the facility leadership acknowledged the non-compliance during the surveyor’s discussion.
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