Do you soley use Section G for careplan ADLs

montecarlo64, ASN, BSN, LPN · Oct 11, 2011

When I do my careplans, I make them to reflect on how the patient is the day that I do them, not just what the MDS reports...Often, the rehab to home patients do improve quickly..I was always told the care plan should give as accurate picture of the patient as possible...Of course, there may need to be a sig change if the ADL changes occur according to the criteria for significant changes. And in that case, there would be another comprehensive assessment along with another care plan update/review..

TigerxLiLy · Oct 11, 2011

Ok, here's another question:

Is there anywhere in the RAI manual stating that you must do the careplan based on all the information in the MDS? (Saying u must date ur careplan as the date u do the MDS even tho ur doing it 7 days later?)

AND! I thought in the RAI manual it states: if the resident admits w/ therapies w/ the goal to become stronger,etc-- and they do-- you do not do a sig change; however our nurse consultant says we do?!

How do you determine what you put as their safest ADL status? ( Do u just go based on the MDS, therapyN or what?)

montecarlo64, ASN, BSN, LPN · Oct 12, 2011

I don't backdate anything..The care plan does not have to be done on the same date as the MDS...When you do the CAAs and choose the option yes that you are going to care plan the trigger, then you need to make a care plan for each one that you decide to do...I usually mark yes on all of the items triggered and if it is not an actual problem, it most likely is a potential problem & care plan it that way...

For the ADL care plan, I put what is accurate for the patient and include what assistance is needed for the direct care staff to provide safe care.. I make an intervention to provide therapy per order, but I do not get more specific than that on what the patient is actually doing in therapy...Just what they are capable of doing or what assist is needed on the floor and for the floor staff to interpret (so they will know how to care for and what kind of assist)...I have had 2 consultants.The 1st one told me not to do a sig change on an expected improvement for a rehab-to-home...Just to do a sig change if they were still there when it is time for their quarterly...My 2nd consultant said that a sig change should be done if there are improvements in 2 ADL areas...But, not if they are fluctuating, as they often do during rehab...If their ADLs fluctuate, she said no sig change is needed, but you need to document that they do have a fluctuation and then when they consistently are improved, do a sig change at that time...I hope that helps:)

TigerxLiLy · Oct 12, 2011

I sure wish I could record what the administrator says and let you guys hear it, then see what yall say

But, yes that does help! I also wish I could show him what you guys have said

PsychNurseWannaBe, BSN, RN · Oct 13, 2011

If you have a rehab patient and are doing the ADL CAAs, I type in that improvement is expected as resident progresses through therapy. I do not sig change them. It is an expected outcome. The comprehensive care plan must be accurate and reflect the current state of the resident. I do not do my CAAs 7 days after I close it out. I was told that we can not do that as we are signing that the CAAs and careplan are completed by the date we put in. So my careplan reflect the most current the resident is as the MDS was just done the day prior. It's all clear as mud. I'm still a newbie and I find that MDS book intimidating.

katoline · Oct 14, 2011

:specs: I was taught that a careplan is a work in progress. I often do the careplans as i am working on the CAAs simply because i work on so many and often at once, i need to do them while fresh in my mind. if things change the day we actually go to careplan or anytime for that matter, we update. we constantly update careplans in our falls, weights and wounds meetings or in stand up if a change of condition occurred.

When you sign the caas you're signing that they were completed and worked and a decision was made to proceed or not, not that the careplan was completed. you still have seven days from the decision to proceed to do them.

careplanning an expectation of a rehab patient is a great goal. we look at the therapy notes and evals, they have them there and they are the ones we work toward. we don't do a significant change on rehab patients that are improving, they are hopefully going to do that and it may or may not be gradual. what we were told to do a sig change on is if a long term care resident say falls and breaks a hip, returns on therapy and improves to the point they were at before the fall. they were probably made a significant change when they returned post surgery as well. only if someone fx a hip that doesn't get out of bed anyway, continues to be total care and doesn't decline in any other areas would we perhaps not do one. if they are bedridden before, they probably aren't going to get rehab unless short term for positioning or such. same goes for bed/chair bound new tube feeding. may not be necessary, but if they come back medicare, we'll be doing new assessments anyway.

TigerxLiLy · Oct 14, 2011

so the Boss doesnt want the CNA's to have to judge what kind of assistance they need to give to the resident; for instance a res is usually limited assist x 1 but during the MDS 7 day look back she required x 2 after a fall; so naturally we coded the 2 for the transfer! The BOSS wants us to say she is a limited x 2 on her ADL careplan.. Then covers it up to say "you can go back and write in what she really is; but you still need to say she is a x 2 assist.." what the heck!?

He states i cannot say on someone who is a person who goes back and forth between limited to extensive weekly (depending on fatigue level) "limited-extensive assist x1 for transfers" He says we have to go with whatever the MDS says, then state "she may require more assistance when fatigued"... how is that not leaving it up to the cnas to judge!?

I keep feeling this is a Oxy-MORON.

PsychNurseWannaBe, BSN, RN · Oct 14, 2011

so the Boss doesnt want the CNA's to have to judge what kind of assistance they need to give to the resident; for instance a res is usually limited assist x 1 but during the MDS 7 day look back she required x 2 after a fall; so naturally we coded the 2 for the transfer! The BOSS wants us to say she is a limited x 2 on her ADL careplan.. Then covers it up to say "you can go back and write in what she really is; but you still need to say she is a x 2 assist.." what the heck!?
He states i cannot say on someone who is a person who goes back and forth between limited to extensive weekly (depending on fatigue level) "limited-extensive assist x1 for transfers" He says we have to go with whatever the MDS says, then state "she may require more assistance when fatigued"... how is that not leaving it up to the cnas to judge!?
I keep feeling this is a Oxy-MORON.

At our facility we do... let say an admission MDS. We gather and input and close out the MDS. The next day we CAA and CP. In my situation, section G and my ADL CP will more than likely match. So if someone falls and they are bouncing between a 3/2 and a 3/3. I would claim the 3/3 on the MDS, make them a 2 assist transfer and have therapy screen or eval and treat. Then therapy will guide me as to what the resident is. As they progress through therapy they will hopefully get better. Your boss needs to understand that the MDS is a snap shot and some what static, however the CP has to evolve with the current condition of the resident. So in my case if the person who fell was a 3/3 on the MDS and with therapy a few weeks later becomes a 3/2, then the care plan is adjusted to reflect the current condition of the resident.

If I have 3/3 and 3/2, then I adjust the care plan and cue cards to a 2 assist as CNAs should not be deciding how to transfer someone who is not stable. With that being said if someone is a one assist but are needing more assistance then the CNAs are to inform the nurse. Nursing can downgrade, they can't upgrade. The downgrade is only until therapy can get involved again to screen.