Comprehensive Care Plans
Tiresa Parker, R.N., C
Quality Improvement Compliance Specialist
F 279
The facility must develop a comprehensive
care plan for each resident that includes
measurable objectives and timetables to
meet a resident’s medical, nursing, mental
and psychosocial needs that are identified
in the comprehensive assessment.
The Care Plan
Should develop quantifiable objectives for
the highest level of functioning the resident
may be expected to attain, based on the
comprehensive assessment.
Who Should Be Involved?
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Interdisciplinary team (IDT)
Resident
Resident’s family
Surrogate or representative
Physician
Quality Improvement Probes
• Does the care plan address:
 Needs
 Strengths
 Preferences identified in the comprehensive
resident assessment
Care Planning Guides
• The Interdisciplinary Team should show
evidence in the resident assessment
protocol (RAP) summary or clinical record
of the following:
 The resident’s status in triggered rap areas;
 The facility’s rationale for deciding whether
to proceed with care planning; and
 Evidence that the facility considered the
development of care plan interventions for
all RAPs triggered by the MDS.
Care Planning Guides [cont.]
• Interdisciplinary means that the
professional disciplines, as appropriate,
will work together to provide the greatest
benefit to the resident.
 Was interdisciplinary expertise utilized to
develop a plan to improve the resident’s
functional abilities?
Care Planning Guides [cont.]
• Does staff make an effort to schedule
care plan meetings at the best time of
the day for residents and their families?
 How does the staff communicate this
information to the resident and their family?
Care Planning Guides [cont.]
• Does facility staff attempt to make the
process understandable to the resident
and family?
• What happens if residents have brought
questions or concerns about their care to
the attention of facility staff?
Goals for Care Planning
• Increase the staff’s knowledge of the
resident;
• Increase the staff’s knowledge on what
to do regarding resident’s care;
• Incorporate care plans into ongoing
resident chart documentation;
Goals for Care Planning [cont.]
• Simplify and individualize the care
planning process;
• Involve all staff;
• Develop a functional resident- centered
care plan that is actually used by the
staff.
Nursing Process
• Encompasses five steps:
Assessment
Problem Statement
Planning (what is the desired outcome?)
Implementation (how to achieve the desired
outcome)
 Evaluation (was the desired outcome
achieved?)
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Assessment
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Resident
Family/friends
Chart
Previous healthcare providers
Assessment [cont.]
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MDS
RAPs
Fall risk assessments
Braden pressure ulcer risk
Mini Mental
Brief Cognitive Rating Scale
Nutritional assessment
Therapy assessment
Problem Statement
• Is not
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Medical diagnosis
Medical pathology
Treatments or equipment
Diagnostic study
Problem Statement [cont.]
• Staff should avoid legally inadvisable or
judgmental statements such as
 Fear related to visits by spouse
 Impaired skin integrity r/t infrequent turning
 Risk for impaired nutrition r/t to improper
working of feeding pump
 Restraints d/t staff’s inability to handle
resident
Problem Statement [cont.]
• Label
• Etiology
• Signs & Symptoms
Problem Statement – Three Parts
• Label
 Describes an actual or potential resident
problem that nursing care can influence
Example: Alteration in skin integrity
Problem Statement [cont.]
• Etiology
 The related factors that precede, contribute
to, or are associated with the patient’s
problem
Example: Alteration in skin integrity r/t refusing
to turn due to pain r/t end stage cancer
Problem Statement [cont.]
• Signs and Symptoms
 This is preceded by the words “as evidenced by”
Example: Alteration in skin integrity r/t refusal to
turn due to pain r/t end stage bone ca as
evidenced by stage 4, 5cm x 5cm sacral wound
Problem Statement [cont.]

If the resident has the potential to develop
the problem, then only the first two parts
are used
Example: Risk for alteration in skin integrity
r/t to pain and refusing to turn due to end
stage bone cancer
Problem Statement –
Right or Wrong and WHY
• Alteration in mood r/t diagnosis of
depression
• Risk for falls
• Bowel incontinence r/t end stage
Alzheimer’s Disease evidenced by daily
incontinent stools
Problem Statement –
Right or Wrong and WHY [cont.]
• Resident requires therapeutic diet,
because of diabetes
• Indwelling catheter to prevent
contamination to ulcer
• Reduced ability/inability to feed self r/t
dementia with chewing/swallowing
difficulty r/t dysphasia
• Vest restraint d/t hx of falls
Resident Care Plan
• Risk for falls d/t dementia with poor
safety awareness and recent CVA with
right-sided hemiparesis e/b admitted
with a vest restraint for 4 falls from w/c
without injury in last 30 days
Goal Statement
• Goals can be long or short term
• Goals should have an observable,
specific behavior
• Goals should be specific in content and
time
• Goals should be attainable
Goal Statement [cont.]
• Goals should be written in terms of
resident action
• There should be one goal statement to
one problem statement
Goal Statement [cont.]
• Parts of a goal statement
 Subject (S)- Resident or a part of the
resident
 Verb (V) - Action to be performed
 Criteria of Performance (CP) - What is to be
done
 Condition (C) - What is needed (optional)
 Time Frame (T) - When the behavior should
occur
Goal Statement [cont.]
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•
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V Will walk
CP 75 feet
C With aid of rolling walker
T By 5/26/10
Goal Statement [cont.]
S Resident
V Will consume
CP 75% to 100% of all meals
C With feeding assistance of one staff
member
• T Within 30 days
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•
Goal Statement –
Right or Wrong and WHY?
• Resident’s hydration will improve over
the next 90 days
• Resident will be treated with dignity and
respect at all times ongoing
• Will attempt to have resident cope with
his everyday events for 90 days
Goal Statement –
Right or Wrong and WHY?
• Will assist as able without pain
• Maintain with decreased anxiety
• Will be restraint free in 30 days
Resident Care Plan
• Risk for falls d/t dementia with poor
safety awareness and recent CVA with
right sided hemiparesis e/b admitted
with vest restraint for 4 falls from w/c
without injury in last 30 days
• Resident will be free from falls with
significant injury thru (2 weeks)
Nursing Interventions
• Physiological
• Psychological
• Socio-economic
Approaches
• Tells what will be done so that the goal
statement can be achieved
• Intended to alter the etiology, defining
characteristics, or risk factors for a
specific nursing diagnosis
Approaches [cont.]
• Must be
 Realistic
 Measurable
 Achievable within the time frame specified in
the resident goal statement
Approaches [cont.]
• Are actions that you (not the resident)
will take
 Assess pedal pulses
 Offer fluids every two hours
 Discuss with family importance of not
bringing candy to resident
Approaches [cont.]
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•
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Are compatible with medical orders
Are compatible with other therapies
Are goal-directed and purposeful
Are safe
Approaches [cont.]
• Consider the resident’s individuality
• Verbs of caution:
 Reassure, teach, support, counsel,
encourage, force, provide, reinforce, and
maintain
Resident Care Plan
• Risk for falls d/t dementia with poor
safety awareness and recent CVA with
right sided hemiparesis e/b admitted
with vest restraint for 4 falls from w/c
without injury in last 30 days
• Resident will be free from falls with
significant injury thru (2 weeks)
Resident Care Plan [cont.]
• Approaches
 Falls evaluation
 Restraint evaluation for least restrictive
device and/or elimination of restraint
 Physical therapy screening for positioning,
restraint reduction, transfers, strengthening
 Pharmacy review for medication side effects
Resident Care Plan [cont.]
• Monitor resident for side effects of
decreased mobility r/t to restraint to
include but not limited to:
 Pressure ulcer
 Decline in bowel and bladder status
 Increased agitation
 Pain
 UTIs
The presentation and related material was prepared by QSource, the Medicare Quality Improvement Organization (QIO) for Tennessee, under a contract
with the Centers for Medicare & Medicaid Services (CMS), a federal agency of the Department of Health and Human Services (HHS). Contents do not
necessarily reflect CMS policy. QSource-TN-PS-2010-12
Tiresa Parker, R.N., C
Quality Improvement Compliance Specialist