Long-Term Care Survey Alert

What do anxiety, confusion, poor adjustment to nursing home placement and psychotropic drug use have in common?

"They're all really part of the same problem for care planning purposes," says Judy Smith, a geriatric nurse practitioner and president of Clinical/ Operational Innovations Corp. in Indian Hills, CO.

Using a nursing diagnosis structure, Smith would condense the five problems into one: "Anxiety related to confusion and recent nursing home placement evidenced by episodes of crying." The psychotropic drug in this particular case is an intervention prescribed to treat the anxiety.

That kind of problem consolidation avoids a lot of paper, wasted time and confusion not to mention an F tag (F279) if surveyors find your care plan doesn't provide a clear map for resident care, says Kathy Hurst, a nurse and attorney with Hurst Consulting in Chino Hills, CA.

Say a resident is at risk for falls because he is confused, takes a psychotropic medication and has an unsteady gait. The care plan in such a case will often state that the resident is at risk for falls. "But there will be separate care plans for confusion, psychotropic meds and the unsteady gait," notes Hurst.

As an alternative, the care plan could state: "Resident at high risk for falls due to confusion, unsteady gait and psychotropic medication," she suggests. Then your interventions would address each of these risk factors. That way, you condense four care plans into one "because the issue that places the resident in harm's way is the risk of falls," Hurst says.

Another problem is that staff often create multiple and huge care plans to address pressure ulcers when a resident is really at risk for skin breakdown due to nutritional issues, incontinence and immobility, Hurst points out.

Once staff gets the knack of how to consolidate resident problems, they will start viewing the resident's health risks and problems in a more holistic way. "The staff can then integrate the resident's problems and issues rather than treating each of them in isolation as if they didn't have anything to do with each other," Hurst maintains. In this way, staff won't lose sight of the "big picture."

While this approach simplifies care planning and encourages holistic care, some surveyors might not "get it" initially and will need you to explain the concept to them. "Conceptually you have to be able to explain your process in a way that makes sense, showing how it leads to a clear plan of care that all members of the interdisciplinary team can follow easily," Hurst says. Also, the facility needs to be consistent in its care planning approach.

Your facility can develop a brief policy and procedure for care planning that says the staff may piggyback problems if a problem is a risk factor to the primary concern, Hurst suggests.

How do you know if the problem statement linking the resident's health issues is on target? The answer lies in the ongoing care plan evaluation. In the example involving the resident at risk for falls, you'd ask: Did the plan's restorative nursing care aimed at improving the resident's gait also decrease his falls? What impact did adjusting or eliminating the resident's psychotropic medication have on his rate of falls?

As for the resident with anxiety due to nursing home placement and confusion, "interventions designed to ease the resident's transition to the facility and engage the person in activities and relationships should alleviate the anxiety, as would interventions that oriented the person and decreased confusion," says Claire Hoffman, a nursing consultant with Hoffman Associates in Royersford, PA.

If these interventions are successful, the resident's need for an anti-anxiety medication should also decrease unless the medication itself is contributing to the resident's anxiety and confusion.

Care planning is always a circular process, Hoffman emphasizes. The evaluation feeds back into the assessment and analysis in determining whether a problem has resolved or improved, persists or is getting worse and why.

Care planning is also a creative endeavor. "There is a good amount of variation in how the resident's problem can be stated and in developing interventions," Smith emphasizes. "Telling a nurse how to state the problem or exactly how to craft a care plan is like telling an artist how to paint a picture."