Health inspection·May 15, 2025

F 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. Based on interview and record review, the facility failed to ensure one of three sampled resident (Resident 1) plan of care was coordinated with hospice (type of care that focuses on the comfort and quality of life of a resident with a serious illness that is approaching the end of life, often includes emotional and spiritual support for both the resident and their loved ones) care. This failure had the potential for Resident 1's care needs to go unmet. Findings: During a concurrent interview and record review, on 6/3/25 at 11:55 a.m. with Director of Nursing (DON), Resident 1's medical record was reviewed. DON stated Resident 1 started hospice care on 12/11/24, DON stated no IDT (interdisciplinary team- group of professionals consisting of attending physician, a registered nurse responsible for resident care, a nurse aide responsible for residents care member of the food and nutrition services, who assess, coordinate, and manage each resident's comprehensive needs) conference was held at the start of hospice for Resident 1. DON stated IDT conference should have been held once Resident 1 started hospice care. Resident 1's IDT Conference, dated 1/22/25 was reviewed. DON stated the IDT Conference indicated Dietary, Activities, and a Social Services team member, hospice nurse, and Resident 1's RP were present for the IDT conference. DON stated a facility nurse was not present for the IDT conference. Resident 1's care plans were reviewed. DON stated only two of Resident 1's care plans were updated when Resident 1 started hospice care. DON stated the expectation was Resident 1's care plans should have been updated to reflect coordinated care with hospice and a facility nurse should be present for the IDT conferences. During a review of the facility's policy and procedure (P&P) titled, Hospice Program, revised January 2014, the P&P indicated, 2. Hospice providers who contract with this facility are held responsible for meeting the same professional standards and timeliness of service as any contracted individual or agency associated with the facility. 4. When a resident participates in the hospice program, a coordinated plan of care between the facility, hospice agency and resident/family will be developed and shall include directives for managing pain and other uncomfortable symptoms. The care plan shall be revised and updated as necessary to reflect the resident's current status During a review of the facility's P&P titled, Care Plans - Comprehensive, revised September 2010, the P&P indicated, Our facility's Care Planning/Interdisciplinary Team, in coordination with the resident, his/her family or representative (sponsor), develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. 6. Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident are interdisciplinary processes that require careful data gathering, proper sequencing of events and complex clinical decision making. No single discipline can manage the task in isolation. The resident's physician (or primary healthcare provider) is integral to this process. 9. The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans: a. When there has been a significant change in the resident's condition; . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555912 If continuation sheet Page 2 of 2