Nursing Assessment and Care Plan Problem Statements

Posted by LTCS on April 15, 2016

How to Write a Care PlanThe problem statement sums up assessment information into a specific functional category. No federal regulation specifies the exact wording or structure of the problem statement, but the MDS 3.0 RAI Users Manual states that problems should be written in functional or behavioral terms. 

Problem statements are traditionally based on a nursing diagnosis. The nursing diagnosis is a problem that nurses can identify and treat. Medical diagnoses can be part of the problem statement, but not the actual problem itself. The most commonly used nursing diagnoses are the ones approved by NANDA, the North American Nursing Diagnosis Association, and are grouped by functional health patterns. 

Elements often included are:

Whether the problem is actual or potential

What the problem is related to, such as medical diagnosis

Objective signs and symptoms of the problem, such as physical assessments and observations

Subjective data, such as the resident’s complaints and nonverbal messages 

The first part of the problem statement describes the resident’s actual or potential functional deficit:

Activity Intolerance 

Medical diagnoses can be added to the statement with the words “related to”:

Activity Intolerance related to COPD 

Objective and subjective data can be specified in the form of the words “as evidenced by”:

Activity Intolerance related to COPD

As evidenced by:

Shortness of breath

Resident verbalizes fatigue when walking in corridor 

Federal regulations are specific that the facility is responsible for addressing all needs and strengths of residents regardless of whether the issue is included in the MDS or Care Area Assessments (CAAs)

A sound practice for care-planning is to follow a check-list of problem identification: 

Address all problems triggered in the CAAs.

Review MDS sections and entries.

Review the resident’s entire chart.

Review the resident’s list of medical diagnoses and all medications.

Focus on the resident’s particular and individual strengths, needs, and preferences. These may become clearer during the care plan meeting, working with the care plan team.

Review the Quality Indicators and Quality Measures triggered by the MDS.

Read all quarterly assessments such as falls, restraints, etc.

The problem should be dated and initialed when entered, changed, or deleted. 

Complete Nursing Care Plans for Long Term Care – 143 Nursing Care Plans for Long Term Care in the book and on the CD 

Staffing Data Submission

Posted by LTCS on January 21, 2016

Long Term Care Nursing PolicyLong term care facilities will be required to electronically submit staffing information based on payroll to CMS beginning July 1, 2016. CMS will use the data to monitor staffing levels and employee turnover and tenure, which can impact the quality of care delivered. 

Facility staffing information will be posted on the CMS Nursing Home Compare website used in the Nursing Home Five Star Quality Rating System. 

CMS Staffing Data Submission Source Documents and Training Materials

2016 MDS OBRA Assessment Scheduling Calendar

Posted by LTCS on December 30, 2015

Director of Nursing Book

The 2016 MDS OBRA Assessment Scheduling Calendar is ready. Receive this valuable tool Free with your book purchase. 

Call 812-606-7882 for information about Volume Discounts.

Increasing Reimbursement in Long Term Care

Posted by LTCS on November 14, 2015

Money Stethoscope Long Term Care Costs Director of Nursing BookThere are many ways the MDS coordinator can increase the reimbursement level of the facility. While quality of care is the top priority, working to get the top level of payment that is justifiably due for services is of the utmost importance. Increased funds produce more resources for care. 

Know the Federal and State Regulations. MDS data and documentation out of compliance due to errors or lateness risk having assessments being paid at the default rate, the lowest rate of payment. 

Be familiar with the documentation requirements of skilled care. Knowing the requirements of skilled care provides opportunities to spot residents falling into higher reimbursement levels upon admission or when the level of needed care changes. Making sure the required documentation is in place assures that the facility will be paid for those services. 

Know the criteria for RUG IV categories. Many elements of the MDS effect the RUG IV categories, and being familiar with them will help spot aspects of care that might otherwise be overlooked. 

Use Grace Days to capture a higher RUG IV score. One of the reasons the Grace Days exist is to enable the facility to capture services for higher reimbursement. Work with the Therapy departments to set the ARD to capture higher Rehabilitation categories. 

Monitor residents for changes that could alter the level of care. Scheduling Significant Change assessments when they are needed not only keeps the Care Plan appropriate for the resident’s needs, but it can also capture higher payment rates do to the increased need for care. Read the 24 Hour reports, attend Stand-up meetings, and examine the Physician’s telephone orders daily to catch changes.  

Schedule assessments to capture higher RUG IV categories. Although Quarterly assessments can be no later than 92 days of the completion date of the last assessment, it is perfectly legitimate to schedule them earlier than the 92 days. 

MDS Tools for Reimbursement and Scheduling 

Article Archives