Long-Term Care Survey Alert

Caveat care planners: If your facility uses a prefabricated or “canned” care plan, make sure to tailor the “one size fits all” approach to each resident. If a care plan isn’t individualized, surveyors can cite you under F279 (comprehensive care plans) and/or for quality of care if the resident has a negative or a potential negative outcome as a result.

Most standardized care plans address a specific problem, such as pressure sores, immobility or peripheral vascular disease. “Yet you can’t just say, ‘Oh, this patient has a pressure sore and here’s a great care plan for that ... I’ll just put it in the chart,’” advises Kathy Hurst, a nursing consultant in Chino Hills, CA. If you do, you may end up with a care plan for a person who is tube fed that says, “Make sure resident eats 75 percent of meals” — an obvious red flag for surveyors.

“If staff does not understand how to individualize the standardized care plans, their use is more detrimental than worthwhile,” Hurst emphasizes.

Even so, most nurses agree that the readymade care plans have their place. “For those who talk about the ‘evils’ of canned care plans, I’d ask: How important is it for a professional nurse to write ‘Resident will be turned and positioned every 2 hours’ for every resident each quarter?” asks Steven Littlehale, chief clinical officer of LTCQ Inc. in Bedford, MA.

MDS, QIs Can Help

The resident assessment instrument provides a framework for selecting individual prefabricated care plans as building blocks for the resident’s comprehensive care plan. “The minimum data set leads the staff through an assessment,” Littlehale says. “And the resident assessment protocol triggers identify the resident’s opportunities for improvement or potential and actual problems.

“Then Section V of the MDS helps staff determine — yea or nay —whether to include what’s been triggered during the assessment as part of the care plan,” Littlehale adds. “The quality indicators, also generated by the MDS, should be linked to the care plan. If a resident triggers a QI, make sure the care plan addresses it,” he emphasizes.

Care planning staff can also use the customary routine section (AC) of the MDS to incorporate the resident’s unique preferences for daily living into a standardized care plan. “If the resident has specific dietary preferences checked in this section, those should be on the plan of care,” says Littlehale. The same is true for the resident’s preference for one form of bathing (shower vs. tub bath) or a time of day for the bath. “All of that is on Section AC and if the staff fills that section out in earnest, it should be a road map for the care plan,” Littlehale explains.

Include CNA Input

To individualize the care plan, facilities need a forum to include the CNAs’ knowledge about the resident. Yet CNAs are often too busy caring for patients to attend a meeting off the floor for 30 minutes. Littehale’s solution: take the meeting to them.

“By performing care planning rounds in the resident’s room with the resident truly at the center of the staff’s attention, and with family present, the nursing assistant can step into the room and provide her input,” Littlehale explains. The resident/family can then validate and add to the information provided by the CNA, if needed.

The resident-centered rounds also provide a good opportunity for the nursing assistant to provide input as to whether a planned intervention is realistic.

“That prevents care plans that specify a resident will be walked three times a day when the resident hasn’t walked in two years,” says Littlehale. “ It also prevents those types of errors from being carried forward,” he notes.

The care planning team should also ask CNAs:

What do you do that’s special and unique for this resident?

Then make sure to include that information on the care plan, Kardex and flow sheets.

Can the Generalized Interventions

Watch out for any overly generic interventions from the “canned” care plans, suggests Judy Smith, a geriatric nurse practitioner and president of Clinical/ Operational Innovations Corp. in Indian Hills, CO. In her view, common examples include directives such as “Provide positive feedback” or “Approach resident calmly.”

Instead, craft more specific instructions geared to a resident’s condition or situation.

An example might include: “Approach resident from the front” for a resident with peripheral vision loss who startles when approached from the side. The care plan might specify the specific type of positive feedback, such as nonverbal cues, that an individual resident seems to find most motivating.