Comprehensive Care Plans

Tiresa Parker, R.N., CQuality Improvement Compliance Specialist

F 279The facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident’s medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment.

The Care PlanShould 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• Resident’s 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 resident’s status in triggered rap

areas; The facility’s 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 resident’s 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 staff’s knowledge of

the resident;• Increase the staff’s knowledge on

what to do regarding resident’s 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 staff’s 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 patient’s 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

Alzheimer’s 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?• Resident’s 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 resident’s 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., CQuality Improvement Compliance Specialist