care plan meetings in LTC

blueeyes827 · Feb 21, 2004

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!

:uhoh21: Hi...............You are correct that the careplan should be based on the rap triggers............how ever the rap triggers do not hit everything. We do a medical managment meeting two days before care conference with families and this works well. The interdisplinary team meets and goes over the mds and then decide as a team the number one problem, number two and sometimes number three. Most times the resident has one problem that impacts all other areas. Diagnosis can be used in the problem statement such as: Alteration in cognition related to multi-infarct dementia, depression which impacts adl care, communication, mobility, activity, mood and behavior etc. We also use just not the careplan as the plan of care. We refer to the med, treatment sheets, adl directives, physician orders because they are all part of the care plan. We do put down specific goals and specific interventions for that resident. If this doesn't make any sense then e-mail me and I will give you more specifics. State surveryors always tries to tell us how to careplan based on their personal preference. We do have to base it on our mds and the specific needs for that resident.

Susan

blueeyes827 · Feb 21, 2004

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!

:uhoh21: Hi............I forgot to give my e-mail address.............it is [email protected]..................sorry about that...........

adrienurse, LPN · Feb 21, 2004

hi, yes raps being trigored is very good (omg I finally know what you're all talking about with all this freaken mds stuff!), but is only meant to supplement (not replace) actual team decisions. From my experience, people are much more likely to follow through on a careplan if they were consulted when creating it.

FrazzledRN · Feb 29, 2004

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!

Hi!

I am the MDS cooridator from a 120 bed skilled facility. We have our care conferences every Monday morning. We go over our assessments that were just recently completed. This way we can judge if they will become significant changes and discuss it with the team so the documentation in each perspective area jives. ALso if there is any question regarding anyone elses data we can discuss it then. I feel it would be very difficult and needless to say not very worthwhile to do the conference before the assessment was even complete. Regarding care planning-yes definitely careplan the triggers, but you can also add in RAPS if you feel they deserve mentioning and care planning. For example if you feel that a resident is a fall risk but perhaps for whatever reason they did not trigger a fall RAP then you can add it in and care plan it. When I am doing my assessment I keep a list on the back as I am going of any problems and potential problems that require a care plan and then use this along with my RAP triggers to evaluate what needs care planned. My theory in our facility is careplan as much as possible that relates to that resident's status. From meds to behaviors if it causes a problem or is a potential for a problem then care plan it. (If Mr. G. is angry about being placed in a nursing home-then he is at risk for alteration in coping and for depression.) (If Mrs. M. has a stage IV decub then we definitely care plan the skin but also pain- and at risks for infection), etc...Psychotropic drugs, incontinence, etc..any problem or potential problem as well as anything that staff, etc. should be aware of. If Mr M. refuses to have female staff bathe him then I put that on the care plan, so everyone can be aware. You can add the diagnoses into your problem and still use the nursing diagnoses. "At risks for decreased cardiac output due to diagnosis of first degree AV block with pacemaker insertion" or "At risks for adverse effects from Coumadin use due to diagnosis of atrial fibrillation", etc. "AT risks for skin integrity impairment due to diagnosis of PVD or DM", etc.

When I came into this position the previous survey had an MDS cites/due to items being RAPPED but not on the care plan (pretty stupid thing to do) but since I have been the coordinator and have pretty much careplanned as much as possible without red flagging anything for surveyors...it has worked and we have had no MDS cite in the last 3 years.

Anyway, the more you do them and the more you learn the residents the easier it will become for you.

Good Luck! :)

mandykal, ADN, RN · Mar 5, 2004

I'm not a nurse but I'm curious to exactly what is "Rap?"

TooBusyRN · Mar 19, 2004

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.

Long Term Care Columnist / Guide · Mar 19, 2004

When I was an MDS coordinator, I developed my own form for the CNAs and nurses to use to chart their observations on each resident whose care conference was due the following week. It was a very simple form on which all they had to do was circle numbers from one to four, denoting how much assistance the resident needed and how they were coping with life. This helped me greatly in developing the MDS and writing RAPs; it also helped the staff feel they were included and gave them some ownership of the care plan. :)

MDSnursing · Oct 16, 2006

Hello There!

Please forgive me for restarting a thread that is two years old. I found it to be quite informative. I am new to my position as a MDS coordinator~about a year now. Had about a month of training however only on MDS', as my predecessor hated care conferences, care planning, as well as Rap summaries. Unfortunately, I need some help here pretty quickly if anyone might be available. We have been through three DON's in the past year. Our newest one used to work here as a Nac, then as a Rn, and left for personal reasons. Fortunately our Administrator convinced her to come back as Don, and she is wonderful as a teacher. She has been a Unit Manager at another facility, and was involved in the care planning process. I have been writing my Rap summaries based on what out QAn nurse had advised me when I asked for assistance about a year ago on references, and just what is it that surveyors are lokking for? She said the same as what another poster said in this thread about care plans. You should be able to read a RAP summary and know exactly who is being discussed without a resident name. And she advised narrative summaries.

Now jump to this years surveys. We got an F-Tag due to my Rap summaries "Being too difficult to follow." OMG. So I have fixed that by starting with an intro to the res, a med list, and diagnosis. Then I follow with seperating Rap summaries by paagraph, instead of essay type. Ok, DON and ADmin are happy with that. But, Another F-Tag is that I did not addres Delirium in my summaries. I over addressed Cognition thinking that it should cover it.

AS part of our Plan Of Correction- Admin is requesting from me an example RAP summary for Delirium, as well as a definition of Delirium, and common triggers/causes of Delirium. (Admin & DON are extremely supportive, and know how much of a perfectionist I am)

Please help!! Does anyone out there have a good example of a RAP summary for Delirium, and can outline for me some common interventions and things important to address?

With Much Appreciation,

Dara

Todd SPN · Oct 16, 2006

Hello There!
Now jump to this years surveys. We got an F-Tag due to my Rap summaries "Being too difficult to follow." OMG. So I have fixed that by starting with an intro to the res, a med list, and diagnosis. Then I follow with seperating Rap summaries by paagraph, instead of essay type. Ok, DON and ADmin are happy with that. But, Another F-Tag is that I did not addres Delirium in my summaries. I over addressed Cognition thinking that it should cover it.
AS part of our Plan Of Correction- Admin is requesting from me an example RAP summary for Delirium, as well as a definition of Delirium, and common triggers/causes of Delirium. (Admin & DON are extremely supportive, and know how much of a perfectionist I am)
Please help!! Does anyone out there have a good example of a RAP summary for Delirium, and can outline for me some common interventions and things important to address?
With Much Appreciation,
Dara

Just from what you have written, I wonder if you are over thinking this. By this I mean delirium has more than one etiology and you should only have to address the one specific to the resident. You should be able to identify the etiology by the dx on the face sheet and the h&p. The RAP summary should be just that, a summary stating the cause. This summary shows the state you are aware of the disease and are addressing it. It sounds to me like you think your bosses are asking for an all encompassing report on delirium and I would question that. Why not write a RAP summary on the resident the state felt was lacking. For your bosses you could throw in the general definition followed by the etiology to this particular res. You might also consider purchasing "The Merck Manual" to help you out.

Todd