Long-Term Care Survey Alert

These strategies will keep you from singing the survey blues.

The Resident Assessment Protocols can be a helpful tool for care planning if you make them work for you rather than create more work or confusion.

Start by nailing down which MDS responses triggered a particular RAP. "If you don't identify what triggered the RAP in a particular case, you won't know how to care plan," says Joan Brundick, BSN, RN, Missouri State RAI Coordinator.

Example: If MDS item J1f (dizziness) triggers the falls RAP, the RAP review would focus on the causes and interventions for dizziness, the RAI manual notes. While reviewing the RAP, the team may find the resident has other fall risk factors. But knowing the triggered condition "clarifies or possibly rules out certain avenues of approach to the resident's problem," the RAI manual states.

Think of the RAPs as a tapestry for an individual resident that creates a picture of what's going on with the person. With that in mind, the team should interrelate the different RAPs, suggests Susan LaBelle, MSN, RN, a consultant with LTCQ Inc. in Lexington, MA. "If you look at the RAPs in a linear way, you can't interrelate how one condition and risk factor affects another RAP," she cautions.

Good question: For example, "if the incontinence RAP triggers, what effect is the incontinence having on the person's psychosocial well-being, pressure ulcers, etc.?" LaBelle asks.

Keep in mind that just because a RAP triggers doesn't mean the resident has a problem or one requiring a change to the care plan, observes Nathan Lake, RN, an MDS and long-term care expert in Seattle.

Say a resident taking a psychotropic medication triggers the falls RAP. But the person has been on the medication for many years without ever taking a tumble. You'd document the situation and explain that the person has excellent balance, and that the care plan already includes interventions to monitor for extrapyramidal effects and gait changes, etc., Lake says.

Two other examples: A continent patient wears an incontinence brief post-op because it's easiest to slip on after a hip repair. Coding the brief in Section H triggers the urinary incontinence RAP, even though the resident doesn't have that problem, notes Holly Sox, RN, MDS coordinator for NHC Healthcare- Lexington in West Columbia, SC.

"Or a person may be missing two teeth, which will trigger the dental RAP," Sox adds. "But he doesn't want to fix [his teeth] and can eat and is perfectly happy as he is."

You absolutely do have to document such situations and explain your rationale for care planning an issue or not. Including "this is why we did or didn't do this" statements is very important, Sox stresses.

When you do care plan an issue, identify a problem statement that addresses the identified issue, a measurable goal and interventions to achieve that goal, advises Marilyn Mines, RN, RAC-C, BC, director of clinical services for FR&R Healthcare Consulting in Deerfield, IL.

Sample goal: If the resident isn't involved in activities and sits and stares at the wall or TV, the goal might be "for the person to express interest in and be involved in an activity 20 minutes a day." Also, make sure the nursing notes address the problems identified in the care plan, including an evaluation of whether the interventions appear to be working. If not, reassess the resident and revise the care plan.