I am a fairly new MDS Coordinator at a LTC facility. I am curious to know how other people conduct their care plan meetings. We are care planning weekly for residents that are due for MDS assessments that week. Shouldn't the process flow to where you complete the mds first and then go onto care planning. I feel like I am not being thorough when I do the care plan meeting before completing my assessment. We also, had a state surveyor come in on a complaint. She stated we should be care planning residents diagnosis. Is this true and if that's the case what a job........I was under the impression that you care plan according to what the RAP triggers. I geuss the question is how to care plan in a nursing home environment???? Any resources regarding this would be great!
Care Planning and MDS completion should go hand in hand. Our facility has care plan conferences on Wednesdays with families, residents (if they are cognitively able to provide input), and the entire interdisciplinary team (social, activities, dietary, DON or ADON, and MDS/Care Plan Coordinator. Often there are things that the members of the team come to the table with that haven't triggered on the previous MDS that still need to be care-planned and possibly added to the quarterly/annual MDS that will be due the next week. (our residents are care-plan/MDS conferenced the week before the MDS is due)
Also, we have quarterly assessments that are required to be completed that aide in completion of the MDS/CP. Most are Briggs forms and include Fall Risk, Dietary Assmt, Elopement, B/B function, Skin Assmt, etc. It is vital information that the MDS coordinator needs to have to completely submit a correct MDS for that resident. In some facilities, the charge nurses complete the quarterly assessments, and in others the MDS/CPC does them. But the MDS coordinator must have a good working knowledge of each resident and their particular condition(s) in order to complete all the assessments, or he/she must be able to go into the chart and get this information from the most recent documentation by ALL departments. If all the team members aren't completing their documentation, it isn't possible to get a completely accurate assessment. I personally feel that the charge nurses don't have time to complete these assessments, but if they are doing their bi-weekly/monthly summaries accurately, then all the info the MDS/CPC needs will be there for nursing.
A state surveyor told me something when I was a new DON and she was in her 'teaching mode.' I have remembered it and preached it to all my MDS/CPC's since then. You should be able to take a stack of care plans for your facility WITHOUT ANY NAMES ON THEM, throw them out on the table and pick each one up, read the problems, and recognize what resident that care plan pertains to. That is truly individualized care-planning. And when you think about it, think about your residents and realize that every single one of them has some certain thing about them that makes them an individual. Capitalize on that when you are care-planning and you'll never go wrong. Cookie cutter care plans don't do nurses, CNA's or residents any good at all.
Last edit by TooBusyRN on Mar 18, '04