AAPACN is dedicated to supporting post-acute care nurses provide quality care.

Strengthen Care Plans to Reflect the Residents’ Needs

by Michele Mummert, RN, RAC-CT, RAC-CTA, DNS-CT, Director of Research and Development, The Compliance Store

Care planning is the foundation of resident care in the long-term care setting. Everything done to care for the resident rests in the care plan. Inadequate care plans that do not appropriately address the resident’s individual needs and goals, and do not have sound, appropriate interventions may impact the resident’s quality of life, the quality of care and services rendered, and could result in survey citations. That is why it is critical to lay a good care plan foundation at the beginning of a resident’s stay and continue to adapt it to the changes the resident experiences throughout the duration of their stay.

Care plans are a tool designed to document the resident’s preferences, needs, or risks, along with their goals for care and interventions aimed at reaching or maintaining those goals. Care planning is an interdisciplinary process, involving many members of the healthcare team and bringing their collective knowledge and experience together to help the resident achieve the goals of care that they have set. It provides continuity of care and is the communication tool for all disciplines to know and understand the care needs of the individual residents under their care. Care plans take into perspective not only the physical needs of the resident, but also the spiritual, social, and psychological aspects of the resident as well. 

The Centers for Medicare & Medicaid Services (CMS) states in Appendix PP of the State Operations Manual, under §483.21 Comprehensive Person-Centered Care Plans, that it expects care plans to be person-centered, consistent with resident rights, and “include measurable objectives and timeframes to meet a resident’s medical, nursing and mental and psychosocial needs…” to include a resident’s cultural views and any trauma-informed issues that they may have. In person-centered care, the resident is the focal point. The facility supports the resident’s choices and goals for care, taking a holistic approach to planning their care. Whether utilizing a traditional medical/nursing model or “I” care plan format, the form and style are not as important as the information contained within the care plan, and the foundation of an effective care plan starts with assessment.   

Assessment begins with collection of data to identify the resident’s areas of need. It may be objective or subjective, with the information coming from many sources such as a history and physical, discharge summary, progress/consultation notes, physical exam of the resident, and verbal information from the resident, family members, friends, or caregivers. Critical thinking skills are important when determining what issues or areas need to be care planned based upon the information collected during assessment.

Once the assessment is completed, the next step is identifying what areas need to be considered for care planning and initiation of the care plan. For the newly admitted resident, CMS expects facilities to establish a baseline care plan within 48 hours of their admission, which should include the minimum healthcare information necessary to provide proper care until the comprehensive care plan is established. The baseline care plan should not only include the admission orders and information from the transferring provider, but also incorporate information from discussions with the resident and/or resident representative.  

After the baseline care plan is in place, the comprehensive care plan can be established and completed.  The Minimum Data Set (MDS) is completed by the nurse assessment coordinator (NAC) and other interdisciplinary team (IDT) members to show the resident’s clinical condition, cognitive and functional status, and any use of services. Once the MDS is completed, Care Area Assessments (CAAs) may be triggered based on certain information inputted into the MDS to alert the NAC that a particular area(s) may need to be considered for care planning. The MDS, however, may identify a resident risk, weakness, or need that may not trigger a CAA. In this instance, the NAC should be mindful that although it may not have triggered a CAA for a care plan determination, care planning may still need to be considered and carried out.

Even when the comprehensive care plan is completed, the work is not done. Care plans are fluid documents and require updating to reflect the resident’s current status. Review and revision of care plans should not be done only during quarterly, annual, or significant change MDS assessments, but throughout the resident’s stay. Failure to update care plans to meet the current needs of the resident could impact the quality of care being provided or result in survey citations. Having a strategy to ensure that care plans are up to date and meet the resident’s needs can mitigate these issues.

While there is no specific strategy that spells out how to ensure that changing resident care needs are being captured and revised on the care plan, here are some tips to consider to strengthen those care plans:

  1. Review 24-hour reports or shift reports to see what is going on with the residents. Pay close attention to residents who have had falls, are on new medications, have infections, experience new or worsening behaviors, develop wounds, or any other unusual changes in condition. Make note of who, what, how or why, and review the relevant care plan(s) to make additional updates to the care plans.
  2. Be attentive in meetings, paying particular attention to reports of changes in resident status, and make note of them. Staff meetings, huddles, care plan meetings, IDT meetings, or even informal family/resident conversations can yield new information that may necessitate revision of the care plan. 
  3. Make rounds and talk with staff about what’s going on with the resident. Observe residents in different settings to look or listen for subtle cues of changes from the resident’s norm.
  4. Review physician or practitioner’s orders, progress notes, consultation notes, therapy evaluations and progress notes, and social service, dietary, or activity/recreation notes to detect changes.
  5. Don’t solely rely on computer-generated care plans. These care plans provide standard problems, goals, and interventions and are a guideline in the care planning process. Review the generated care plans and adjust the problem, goal, or intervention(s) as it fits the resident or create customized care plans specific to the resident’s needs. Remember, the resident is the focal point and their care plan must be individualized to their specific needs and goals.
  6. Don’t forget the resident’s voice. Talk with the resident and consider using the resident’s direct words when developing and updating the care plan. This is especially useful in “I” care plan formats, as the resident’s preferences or needs are usually written in the first person.
  7. Try not to put off or wait too long to update the care plan. Make changes during meetings or shortly after so they are not forgotten.

Resident needs and preferences can change along the course of their stay and their care plans must reflect those changes. Vigilance with noting changes in resident needs and making concerted efforts to keep care plans up to date based on those changes is vital to ensuring that the resident is receiving appropriate care and services. By considering some of these tips, staff can be assured that residents’ care plans are reflective of their current needs and paint an appropriate picture when surveyors come to visit.

About The Compliance Store:

The Compliance Store is the only comprehensive online regulatory resource designed for long-term care. It provides anytime access to updated regulatory and government agency information. Thousands of crucial documents are within reach at a moment’s notice, including the only compendium of state regulations available anywhere.