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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