Comprehensive Care Plans

Tiresa Parker, R.N., C

Quality Improvement Compliance Specialist

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The facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a residents medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment.

The Care Plan

Should develop quantifiable objectives for the highest level of functioning the resident may be expected to attain, based on the comprehensive assessment.

Who Should Be Involved?

Interdisciplinary team (IDT) Resident Residents family Surrogate or representative Physician

Quality Improvement Probes

Does the care plan address:
Needs Strengths Preferences identified in the comprehensive resident assessment

Care Planning Guides

The Interdisciplinary Team should show evidence in the resident assessment protocol (RAP) summary or clinical record of the following:
The residents status in triggered rap areas; The facilitys rationale for deciding whether to proceed with care planning; and Evidence that the facility considered the development of care plan interventions for all RAPs triggered by the MDS.

Care Planning Guides [cont.]

Interdisciplinary means that the professional disciplines, as appropriate, will work together to provide the greatest benefit to the resident.
Was interdisciplinary expertise utilized to develop a plan to improve the residents functional abilities?

Care Planning Guides [cont.]

Does staff make an effort to schedule care plan meetings at the best time of the day for residents and their families?
How does the staff communicate this information to the resident and their family?

Care Planning Guides [cont.]

Does facility staff attempt to make the process understandable to the resident and family? What happens if residents have brought questions or concerns about their care to the attention of facility staff?

Goals for Care Planning

Increase the staffs knowledge of the resident; Increase the staffs knowledge on what to do regarding residents care; Incorporate care plans into ongoing resident chart documentation;

Goals for Care Planning [cont.]

Simplify and individualize the care planning process; Involve all staff; Develop a functional resident- centered care plan that is actually used by the staff.

Nursing Process
Encompasses five steps:
Assessment Problem Statement Planning (what is the desired outcome?) Implementation (how to achieve the desired outcome) Evaluation (was the desired outcome achieved?)

Assessment
Resident Family/friends Chart Previous healthcare providers

Assessment [cont.]
MDS RAPs Fall risk assessments Braden pressure ulcer risk Mini Mental Brief Cognitive Rating Scale Nutritional assessment Therapy assessment

Problem Statement
Is not
Medical diagnosis Medical pathology Treatments or equipment Diagnostic study

Problem Statement [cont.]

Staff should avoid legally inadvisable or judgmental statements such as
Fear related to visits by spouse Impaired skin integrity r/t infrequent turning Risk for impaired nutrition r/t to improper working of feeding pump Restraints d/t staffs inability to handle resident

Problem Statement [cont.]

Label Etiology Signs & Symptoms

Problem Statement Three Parts

Label
Describes an actual or potential resident problem that nursing care can influence Example: Alteration in skin integrity

Problem Statement [cont.]

Etiology
The related factors that precede, contribute to, or are associated with the patients problem
Example: Alteration in skin integrity r/t refusing to turn due to pain r/t end stage cancer

Problem Statement [cont.]

Signs and Symptoms
This is preceded by the words as evidenced by Example: Alteration in skin integrity r/t refusal to turn due to pain r/t end stage bone ca as evidenced by stage 4, 5cm x 5cm sacral wound

Problem Statement [cont.]

If the resident has the potential to develop the problem, then only the first two parts are used Example: Risk for alteration in skin integrity r/t to pain and refusing to turn due to end stage bone cancer

Problem Statement Right or Wrong and WHY

Alteration in mood r/t diagnosis of depression Risk for falls Bowel incontinence r/t end stage Alzheimers Disease evidenced by daily incontinent stools

Problem Statement Right or Wrong and WHY [cont.]

Resident requires therapeutic diet, because of diabetes Indwelling catheter to prevent contamination to ulcer Reduced ability/inability to feed self r/t dementia with chewing/swallowing difficulty r/t dysphasia Vest restraint d/t hx of falls

Resident Care Plan

Risk for falls d/t dementia with poor safety awareness and recent CVA with right-sided hemiparesis e/b admitted with a vest restraint for 4 falls from w/c without injury in last 30 days

Goal Statement
Goals can be long or short term Goals should have an observable, specific behavior Goals should be specific in content and time Goals should be attainable

Goal Statement [cont.]

Goals should be written in terms of resident action There should be one goal statement to one problem statement

Goal Statement [cont.]

Parts of a goal statement
Subject (S)- Resident or a part of the resident Verb (V) - Action to be performed Criteria of Performance (CP) - What is to be done Condition (C) - What is needed (optional) Time Frame (T) - When the behavior should occur

Goal Statement [cont.]

V Will walk CP 75 feet C With aid of rolling walker T By 5/26/10

Goal Statement [cont.]

S Resident V Will consume CP 75% to 100% of all meals C With feeding assistance of one staff member T Within 30 days

Goal Statement Right or Wrong and WHY?

Residents hydration will improve over the next 90 days Resident will be treated with dignity and respect at all times ongoing Will attempt to have resident cope with his everyday events for 90 days

Goal Statement Right or Wrong and WHY?

Will assist as able without pain Maintain with decreased anxiety Will be restraint free in 30 days

Resident Care Plan

Risk for falls d/t dementia with poor safety awareness and recent CVA with right sided hemiparesis e/b admitted with vest restraint for 4 falls from w/c without injury in last 30 days Resident will be free from falls with significant injury thru (2 weeks)

Nursing Interventions
Physiological Psychological Socio-economic

Approaches
Tells what will be done so that the goal statement can be achieved Intended to alter the etiology, defining characteristics, or risk factors for a specific nursing diagnosis

Approaches [cont.]
Must be
Realistic Measurable Achievable within the time frame specified in the resident goal statement

Approaches [cont.]
Are actions that you (not the resident) will take
Assess pedal pulses Offer fluids every two hours Discuss with family importance of not bringing candy to resident

Approaches [cont.]
Are compatible with medical orders Are compatible with other therapies Are goal-directed and purposeful Are safe

Approaches [cont.]
Consider the residents individuality Verbs of caution:
Reassure, teach, support, counsel, encourage, force, provide, reinforce, and maintain

Resident Care Plan

Risk for falls d/t dementia with poor safety awareness and recent CVA with right sided hemiparesis e/b admitted with vest restraint for 4 falls from w/c without injury in last 30 days Resident will be free from falls with significant injury thru (2 weeks)

Resident Care Plan [cont.]

Approaches
Falls evaluation Restraint evaluation for least restrictive device and/or elimination of restraint Physical therapy screening for positioning, restraint reduction, transfers, strengthening Pharmacy review for medication side effects

Resident Care Plan [cont.]

Monitor resident for side effects of decreased mobility r/t to restraint to include but not limited to:
Pressure ulcer Decline in bowel and bladder status Increased agitation Pain UTIs

The presentation and related material was prepared by QSource, the Medicare Quality Improvement Organization (QIO) for Tennessee, under a contract with the Centers for Medicare & Medicaid Services (CMS), a federal agency of the Department of Health and Human Services (HHS). Contents do not necessarily reflect CMS policy. QSource-TN-PS-2010-12

Tiresa Parker, R.N., C

Quality Improvement Compliance Specialist