CAAs and care plans

[glm777, BSN, RN]

I recently started a new job and the care plans are done 100% by nursing. When reviewing the CPs for my triggered CAAs I noticed they did not have a CP for antipsychotic Med. So I put one in…and was asked not to do that again. It seems they care plan AP meds under mood-but all that is addressed in the mood CP is that the resident receives the Med. Period. No mention of the risk for side effects, no mention of the need for GDR. No goal r/t the Med at all. I think they care planned “f/b psych service”. I have always put a separate care plan in for psych meds but maybe it doesn’t have to be??

They do the same for incontinence-“provide incontinence care as needed” as part of the ADL care plan. Done. No goal r/t to incontinence, no interventions such as “offer toileting at…” or “check resident every 2-3 hours for incontinence. Just “incontinence care as needed”.

I’ve been doing this 30+ years so maybe I’m still doing it old school?

I appreciate any feedback!

[Talino]

Being the new kid in the block where ignorance is bliss, I can emphatize. I would probably start by printing the triggered CAA worksheet and share with the DON or care planner, seek their insight on how they would analyze the findings, direct you to the source of supportive documentation, and arrive at their care planning decisions. Then make a suggestion to add in "their" care plan your thoughts.

[glm777, BSN, RN]

Their rationale is that it IS in the care plan. It's just not a separate care plan. I told them that I thought that just having it in one of the other CP - as an approach -didn't justify that we considered the category a problem. I've always thought that if we consider a CAA item a problem, we need a goal for that problem and approaches to reach that goal. Just listing it as part of another CP problem (IE: 'incont care as needed" in the ADL care plan) is not enough. They are agreeing that what I proceeded on does belong in the CP - the issue is that I think the problems need to have a separate CP with separate goals and approached specifically for each triggered problem- they do not. Maybe I'm the one who is wrong in this case...