MDS Alert

Follow this guide to care plan and survey success.

Using the resident assessment protocols or RAPs effectively can ensure your care plans are in tune with your residents' needs--and surveyors' expectations.

Step 1: Know which MDS responses triggered the RAP. Facilities often miss this step, especially when triggering is automated or when someone who didn't complete the MDS reviews the trigger legend, cautions the manual.

"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, notes the RAI manual. 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," says the RAI Manual.

Step 2: Review RAPs in tandem. At Extendicare Health Services, everyone on the interdisciplinary team reviews the RAPs triggered by an MDS assessment and discusses what to care plan, says Rita Roedel, RN, national director of reimbursement services for the nursing home company in Milwaukee.

Also look at the big picture: 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.?" asks LaBelle.

Step 3: Weigh whether to proceed with care planning based on a RAP review. 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 the care plan [already] includes interventions to monitor for extrapyramidal effects" and gait changes, etc., says Lake.

2 other examples: A continent patient wears an incontinence brief post-op because it's easiest to slip on after a hip repair. And 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."

The bottom line: You absolutely do have to document such situations and explain your rationale for not care planning the issue, says Sox. Including "this is why we did or didn't do this" statements are very important, she stresses.

Step 4: When care planning, 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," suggests Mines. And make sure the nursing notes address the problems identified in the care plan, including an evaluation of whether the interventions appear to be working.

Step 5: Tap the RAPs as an educational tool. "If you read the problem statements for all the RAPs, you will have taken a mini-gerontology class," says Carol Job, RN, a consultant with Myers & Stauffer in Topeka, KS.

Tip: To get the care team familiar with the RAPs, the team can take a RAP each month and have everyone review it together, advises Sheryl Rosenfield, RN, a consultant with Zimmet Healthcare Services Group in Morganville, NJ.