CARE PLANNING Resident Centered Care Sandra Psiurski, RPC, RPN, CCPCP Quality Review Coordinator, SOK/COK Interior Health Authority August 12, 2014
The many names of a care plan • Kardex • Resident Day / My Day • Flowsheet • RAI 2
Flowsheets & Checklists When using these types of communication to document routine care, ADL’s, vital signs, etc. • The flowsheets become part of the permanent record • Can be used as evidence in court • Check marks and symbols may be used on flow sheets or checklists as long as: – It is clear who performed the assessment or intervention – Each symbol’s meaning is identified in agency policy. CRNBC (2013) Nursing Documentation 3
RESIDENT “MY DAY” 4
KARDEXES A kardex • Allows quick reference to needs of resident • Is a TEMPORARY worksheet to prioritize tasks and manage time • Used to communicate current orders, upcoming tests or surgeries, special diets or the use of aids for independent living specific to an individual client • If a paper format is used, entries may be erasable as long as the assessment , nursing interventions carried out and the impact of these interventions on client outcomes are documented in the permanent health record • When the kardex is the only documentation of the client’s care plan, it is kept as part of the permanent record. CRNBC (2013) Nursing Documentation 5
WHAT IS A CARE PLAN A care plan is a document used to reflect the - Immediate care needs - Long term rehabilitation plan - Situations you hope to improve or stabilize - Identify resident needs and wants - Provide care at or above standards 6
Residential Care Regulation Care Plans must: • Guide the caregiver in protecting and promoting health and safety • Take into account unique abilities, needs and preferences • Care plans are monitored, reviewed, and modified • MUST BE IN INK or computer generated • 81(3) 6 areas required + restraints 7
LICENSING REQUIRED PLANS FOR CARE Immediate Daily Care Needs: • Oral • Nutrition • Activities • Behavior • Falls • Self Administering Medication • Restraint 8
RESIDENT DAY INFORMATION • ORAL : Denture U/L, Remove at night to soak, brush after lunch. Seen by Dental Hygenist annually: last appt Jan 13, 2014 – Refused. • NUTRITION (ADL) – Soft Diet, Adaptive Spoon, assist with opening fluids and uncovering food. Encourage to drink fluid, dislikes cranberry juice and tea. • ACTIVITY: Encourage resident to attend facility activities, provide daily reminders, prefers solitary activities such as sitting in courtyard or bird watching. Likes TV shows on science and history. 9
RESIDENT DAY INFORMATION pg 2 • BEHAVIOR : Resident doesn’t like to be in large groups for more than an hour at a time. If resident begins to get irritable, remove to quiet area. Make sure resident is the last one to be taken to an activity and meals to limit time in a crowd. • FALLS : Last Scott Falls Assessment: April 1, 2014. Risk HIGH. Likelihood this rating will improve with rehabilitation. Protective Devises Used: Low bed, Hip Protectors, Non-slip socks, assist of 1 to bathroom and bed. Report falls to nurse and rehab. • MEDICATION : Only address if resident self administers medications. Include physician order, directions, and medication safety processes in this information. 10
RESTRAINT CARE PLAN RESTRAINT ORDER AND PLAN MUST INCLUDE: • Reason for the use • Type/Nature of restraint - Minimal restraint to be used • Alternatives used prior to restraint order – What was implemented or rejected • Duration : Start date, Reassessment Date, End Date • Monitoring : Safety, Emotional State, Dignity • Date of reassessment • Outcome of reassessment – – Continue Restraint – Remove Restraint Restraints are to be used only when necessary to protect the person in care or others 11
VALUABLE TIP • When doing medication reviews – categorize them by System/Purpose – for example Cardio Endo Gastro Pain Psych PRN Vit/Min 12
INTERDISCIPLINARY TEAM 13
WHAT IS A CARE PLAN • A daily tool to direct resident care and address areas of improving, stabilizing abilities, and acknowledging anticipated decline. • Care plans provide a roadmap to reach a goal \ • M easurable – A ttainable – P ersonal - S pecific 14
Care Plan Care plans • Outline care • Reflect the current condition • Are PERMANENT health records • Must be written in Ink or electronic • Must be up to date • Identify resident needs and wishes CRNBC (2013) Nursing Documentation 15
IDENTIFYING THE ISSUES TO PUT ON THE CARE PLAN • CAPS • PIECES • MEDICAL CONDITION • LICENSING • OUTCOME SCORE CHANGES • RESIDENT WISHES/NEEDS 16
P.I.E.C.E.S. • 1. P-I- E represent a person’s Physical, Intellectual and Emotional health • 2. C refers to Capabilities, to achieve the highest possible quality of life for the person • 3. E- S represent the person’s Environment and their Social self (cultural, spiritual, life story) User Guidelines for the Job Aid Putting it All Together: RAI-MDS and PIECES Integration (2010) 17
RAI - CAPs • Factors that have a need for intervention • Provide information for care planning OUTCOMES • Functional Domains • ADL, Cognition, Pain, Social Engagement... • Measured against standardized testing 18
INDICATORS Worsening behavior, falls with injury, etc. • Identifies areas of: – STRENGTH – OPPORTUNITY for IMPROVEMENT – NEEDED ASSESSMENT 19
RESIDENT FOCUS • THE RESIDENT DIRECTS THE CARE PLAN – – Not the family – Not the staff – Not the management • WHAT IS THE RESIDENT TELLING YOU – – Underlying CAUSE of issues ( Pain, Behavior, Mood, Activity, ...) – ALL ISSUES SERVE A PURPOSE FOR THE RESIDENT – What is unique in the plan to identify it as Mr. Jones? 20
RESIDENT PERSPECTIVE As the main participant in care planning, the issues and goals should be written from the perspective of the resident! • The resident calls out all night and rings the bell when in bed. HOW WOULD YOU WRITE THE INTERVENTIONS ? 21
What if it were written: The resident is afraid of the dark and calls out at night and rings the bell. 22
WHY RAI CARE PLAN • Indicators relate to other areas Pain may affect : – Anxiety – Antidepressant use – Depression WHY? – Social engagement – Sleep – Mood – Behavior 23
WHAT CAUSES THE PAIN? • Investigating WHY something is happening allows us to TREAT the UNDERLYING CAUSE of an issue. • Care plans should be oriented towards: – Prevention – Managing Risk – Preserving Ability – Applying Current Standards – Evaluating Treatment 24
Resident Unable to Express Wishes • Do not ask the family what they want – Ask the family what What would the RESIDENT want . 25
THE PURPOSE OF TRACKING INDICATORS “Result and performance indicators are not an end in itself, but an instrument to trigger reflection and dialogue within the organisation about the causes and potential consequences of interventions . “ Programme of DG Employment, Social Affairs and Equal Opportunities (2013) 26
OUTCOME SCORES Instructions to Print Outcome Report for a care conference Open Goldcare Find the resident’s name Open that resident’s file The report will show up on the next screen On the left- blue vertical bar- press the “Print” at the top Do not use the printer Icon at the very top, this will just give a screen shot 27
MEASURABLE CARE PLAN GOALS MDS 3.0 RAI Manual example : • Subject : Mr. Jones • Verb will walk • Modifiers up and down five stairs with the help of one nursing assistant daily • Time frame for the next 30 days • Goal in order to maintain continence and eat in the dining area 28
How it may look in a care plan 1. Is it easy to understand? M 2. Can you measure it? A 3. Is it attainable? P 4. What is the personal purpose of the goal? S 5. Is it specific? CMS's RAI Version 3.0 Manual, June 2010 29
RISK PERSPECTIVE ** DUE DILIGENCE ** Did the facility do all that it could do to 1) Identify resident needs and wants 2) Provide care at or above standards 3) Reduce risk to resident or others 4) Meet the outcome goals set in the care plan 5) Understand the use of the care plan in meeting the resident needs and wants 6) Are we doing what we say we will do 30
Questions? 31
REFERENCES Baycrest Centre for Geriatric Care (2011). RAI-MDS 2.0 Nutritional Care Resource Guide. Retrieved from https://www.ccim.on.ca/LTCH/RAI/Document/RAIMDS%202.0_Nutritional%20Care%20Res ource%20Guide_April2011_v0.1.pdf CMS’s RAI Version 3.0 Manual: CH 4: CAA Process and Care Planning , May 2013. Retrieved from http://www.aanac.org/docs/mds-3.0-rai-users-manual/11137_mds_3- 0_chapter_4_v1-10_may_2013.pdf?sfvrsn=4 CRNBC (2013) Nursing Documentation. Retrieved from https://www.crnbc.ca/standards/lists/standardresources/151nursingdocumentation.pdf Deschenes, Coleen & Twombly, Christine (2014) The RAI Process: CAAs, Care Planning and Beyond. Harmony University, Harmony Healthcare International, Inc. (HHI) Retrieved from http://www.slideshare.net/HarmonyHealthcareInternational/the-rai-process-ca-as-care- planning-and-beyond Twombly , Christine (2013) What’s New from CMS and Effectively Linking CAAs to the Care Planning Process. Harmony Healthcare International Inc. www.health.wyo.gov/Media.aspx?mediaId= 13602 32
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