MDS

[Lovetobenurse]

What is the best way to update a resident care plan? Let say that a resident has a risk for fall care plan, then a month later she has a fall. Would you add fall to the problem list , then add new interventions or would just add the interventions to the risk for fall care plan? MDS and DON debates over this. Thanks for your help.

[CoffeeRTC, BSN, RN]

Care plans can be updated at any time. As soon as we add or change the interventions, we update the care plan. At risk for falls is still an acceptable problem. They will almost always be at risk for falls. No new careplan is needed.

[CapeCodMermaid, RN]

I would update the care plan with new interventions.

[Nascar nurse, ASN, RN]

I would add the new intervention to the existing fall careplan. What are you using for a goal? "Will have no further falls" is probably not a realistic goal. Often better to have "Will remain free of significant injury related to fall risk"

[CapeCodMermaid, RN]

I never use 'Will have no falls' since that is not reasonable. Will sustain no injury from fall is better. AND if they are self directed and don't want to use the interventions, I care plan that, too.

[Lovetobenurse]

Thank you all for your responses