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Care Planning: A Team Event

A surveyor investigating a resident with multiple falls approaches a nurse and asks why the care plan wasn’t updated with the latest fall prevention interventions. The nurse tells the surveyor that she doesn’t have anything to do with the care plans and that the nurse assessment coordinator (NAC) is who the surveyor should ask. When the surveyor questions the NAC, she states she did not update the care plan because the additional interventions were implemented after the latest quarterly update. This scenario may sound familiar, especially in facilities that assign the NAC all steps of the care planning process, but there are perils to this approach. This article will discuss the dangers of relying solely on the NAC for care planning and offer tips to help the director of nursing services (DNS) involve nursing staff in the care planning process.

The care plan and care planning process

The care plan is a vital tool for communication. It informs staff of the resident’s preferences, problems, strengths, and goals; it instructs them on how to provide care to meet the resident’s specific needs; and it enables the provision of consistent care.

Care planning is the process of developing this individualized, interdisciplinary plan of care for each resident. It is a continuous, deliberate process of identifying resident problems and risk factors and proactively intervening to eliminate or minimize them. Care plan development depends on a thorough, interdisciplinary assessment of the resident’s problems, needs, and strengths, which are documented in the medical record throughout the resident’s stay.

Often, the care planning process is the responsibility of one person, the NAC. However, this practice is inadequate. The care plan is a dynamic process, meaning that it is ever-changing. When a resident’s needs change, such as due to a fall, staff should implement new interventions and update the care plan to reflect those changes. This includes changes that occur after hours and on weekends. If the NAC is the only person who updates care plans, facilities cannot always revise the care plan in a timely manner, as occurred in this article’s opening scenario.

Failing to update care plans timely can lead to many issues, including:

  • Miscommunication to staff
  • Increased risk for residents (e.g., falls, pressure injuries, etc.)
  • Poor quality of care
  • Retraumatization of a resident
  • Survey citations
  • Litigation

Federal Requirements

Multiple F-tags pertain to care plans, yet this article will focus on two: F655 Baseline Care plans and F657 Care Plan Timing and Revision. According to F655 in Appendix PP of the State Operations Manual (SOM), the baseline care plan must—

(i) Be developed within 48 hours of a resident’s admission.
(ii) Include the minimum healthcare information necessary to properly care for a resident, including, but not limited to—
A. Initial goals based on admission orders.
B. Physician orders.
C. Dietary orders.
D. Therapy services.
E. Social services.
F. PASARR recommendation, if applicable (CMS, 2023).

The baseline care plan provides the minimum health information necessary for care and conveys instructions to staff regarding the resident’s needs and preferences. The intent of the baseline care plan is to promote continuity of care and resident safety right after admission. It is a valuable resource for staff to refer to when a resident is new and staff are getting to know him or her. This increases the importance that facilities initiate the baseline care plan as soon as possible.

Floor nurses are the first to meet and assess a new resident. They should also be the ones to initiate the baseline care plan. Leaving the initiation solely to the NAC will not only delay the baseline care plan’s implementation, but it may also mean that the facility will not meet the requirements of F655. For instance, many NACs work Monday through Friday. When a resident admits on Friday evening, the NAC will not develop or initiate the baseline care plan until the following Monday, outside the 48-hour requirement.

After the interdisciplinary team (IDT) team develops the comprehensive care plan, they must review and revise it as well. F657 in Appendix PP of the SOM states that a resident’s comprehensive care plan must be “reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments,” (CMS, 2023). Additionally, the SOM states that staff must revise the care plan based on “changing goals, preferences and needs of the resident and in response to current interventions,” (CMS, 2023).

It is in everyone’s best interest for the IDT to update the care plan in a timely manner with any changes to problems, goals, or interventions. The IDT should include floor nurses and aides. They care for the residents and know their needs better than anyone else. Floor staff also know when those needs change. To apply their knowledge for the residents’ benefit, floor staff should participate in revising the care plan to reflect changed needs. Otherwise, the team may not update it until the next Minimum Data Set (MDS) quarterly assessment, as shown in the scenario above.

Get the team involved

To ensure care plans are up to date, make the process a team event. Involve all staff whose job description allows participation. Although this can be a difficult endeavor, especially in facilities with staffing challenges, it is possible. The DNS can use the following suggestions to encourage staff participation in the care planning process.

  • Set expectations – It is important that the DNS set expectations. Understanding expectations reduces confusion and sets staff up for success. When establishing expectations, be clear and concise and make sure the expectations are attainable. While there may be occasions when staff cannot initiate or update a care plan per expectations, such as when an emergent situation arises that needs the nurse’s time, this should not be the norm. For such occasions, have a back-up procedure to ensure updates occur as soon as possible. Additionally, reinforce expectations frequently and hold staff accountable when they do not meet expectations.
  • Provide training – The DNS cannot hold staff accountable if staff don’t know how to initiate or complete revisions to care plans. Provide training on the care planning process, along with what each person’s role in the process is. Training can take many forms, including lecture, role playing, or hands-on training where staff develop or revise a practice care plan. Allow for questions and ensure staff understand the training.
  • Provide resources – Make sure staff have the resources to do their job. One resource can be a point person staff can go to with questions, such as the NAC or DNS. Another resource would be a tool that staff can refer to when initiating or revising a care plan. AAPACN has several resources to utilize for care planning, including the Baseline Care Plan Tool and the Comprehensive Person-Centered Care Plan Audit Tool and Care Planning Cheat Sheet.
  • Communicate – Communication is key in care planning. Encourage communication between staff and residents to promote development of person-centered care plans. When a change in status occurs, remind staff to update the care plan if needed. Some staff may experience difficulties with the care planning process, such as how to access the care plan to understand current goals and interventions. Foster a culture where staff feel comfortable relaying these problems and work through the issues with them until they feel comfortable.
  • Provide feedback – It’s important that staff receive feedback regarding their efforts in the care planning process—both good and bad. Let them know when they are doing a good job. Conversely, also inform staff when improvements need to be made. Providing good feedback encourages those who are actively using and revising the care plan to continue. By addressing outstanding issues, the DNS helps staff who aren’t quite meeting expectations to focus on their areas of improvement.

The person-centered care plan is the foundation of a resident’s care. It provides staff information and instructions vital for that care. Teamwork is crucial to lay this foundation, keep it updated, and build on it to provide residents great quality of care. It really does take a village, and the care plan is the document that brings the team together.

References Centers for Medicare & Medicaid Services. (2023). State operations manual, Appendix PP – Guidance to surveyors for long term care facilities. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf

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