MDS Alert

Don’t miss the rationale for each answer.

Check your answers here, and understand the rationale with tips from the RAI Manual on pages 4-10 to 4-11, and Jane Belt, MS, RN, QCP, RAC-MT, RAC-MTA, MDS consultant, in Columbus, Ohio.

1. True. Rationale: The overall care plan should be oriented toward assisting the resident in achieving his/her goals.

2. False. Rationale: Individualized interventions should honor the resident’s preferences. “The care plan belongs to the resident,” Belt emphasizes.

3. False. Rationale: Care plans should address ways to try to preserve and build upon resident strengths. “If a resident has strengths, they should be care planned so those abilities do not diminish,” Belt says.

4. False. Rationale: Care plans should be oriented toward “preventing avoidable declines in functioning or functional levels or otherwise clarifying why another goal takes precedence (e.g., palliative approaches in end-of-life situation),” the RAI Manual says. “A resident may have many goals, and sometimes we need to prioritize,” Belt says.

5. True. Rationale: Care plans should manage risk factors to “the extent possible or indicating limits of such interventions.”

6. True. Rationale: Care plans should apply the current standards of practice.

7. False. Rationale: Care plans should evaluate treatment using measurable objectives, timetables, and outcomes of care.

8. False. Rationale: Care plans should respect any resident’s right to refuse treatment. “If the resident refuses, we need to work with the resident to find alternative interventions. It is the resident’s care plan, so it must reflect each person,” Belt says.

9. False. Rationale: Care plans should include alternative treatments when applicable.

10. True. Rationale: Care plans should be crafted with an interdisciplinary approach for improving the resident’s abilities.

11. False. Rationale: The care planning process should involve the respective resident, their family, and/or any representatives, as appropriate. “The regulations requirement involvement of resident and family, if OK with the resident,” Belt explains.

12. True. Rationale: Care plans should assess and plan for care that meets each resident’s goals, preferences, and medical, nursing, and mental and psychosocial needs.

13. False. Rationale: Direct care staff should be involved in the care planning process. “Direct care staff are part of the interdisciplinary team — they need to be involved in care planning,” Belt says.