How One Facility Stays Free of Care Plan Deficiencies.

It's an achievement comparable to straight A's through high school and college, or "10s" in gymnastics -- for the last six of seven years surveyors have found no faults with the resident assessment process of Rockville Nursing Home, Rockville, MD.

We asked Theresa Fraley, RN, Assistant Director of Nursing at Rockville Nursing Home, to tell us about their "perfect" care planning process.

The facility is divided into two 50-bed units, each with a Charge Nurse who coordinates the MDS, enters it in the computer, and formulates the care plan.

Care Plan Meetings

Care Plan meetings are held weekly and include the Dietician, Head of Dietary Department, Charge Nurses, Inservice Coordinator, Administrator, Activities Director, Social Services Director, and the ADON.

For the first 15 to 30 minutes of the meetings they address any changes that have come up with residents, particularly regarding skin condition, dietary intake, level of consciousness, and ADLs. Everyone brings their observations and they discuss approaches to use with the areas of concern. If a concern is not resolved within 14 days and it involves more than one area of a resident's general condition, they look at submitting a significant change assessment.

At the meeting they review each resident's care plan on a quarterly schedule. Residents' care plans are also reviewed when annual and quarterly MDS assessments are due. This process results in each resident's care plan being reviewed at least five times a year.

The MDS and Care Plan

Completed MDSs are reviewed by all at the care plan meeting before being submitted. At Rockville Nursing Home, the Dietitian, Social Services Director, and Activities Director complete the appropriate sections of the MDS and enter the data.

Contract rehabilitation therapy staff chart on a form and Charge Nurses enter rehab data in VistaKEANE Resident Assessment. Ms. Fraley reviews the completed assessments and submits them to the state.

The Charge Nurses review the RAPs triggered by the MDS and make sure they are all covered in the care plan and in their notes in the chart. Social Services staff read the chart for behavior issues to address.

Family members are invited to attend the portion of the meeting addressing their relative's MDS. "About half of our residents' families attend-they find it a good way to get an in-depth report on their family member's condition," says Ms. Fraley.

How VistaKEANE Helps

"VistaKEANE Resident Assessment is definitely easier to use than the product we had before-it asks questions exactly like they are on the MDS. It has simplified our MDS process and we find it very helpful that it generates the RUG score for us.

"We've developed our own care plan language, worksheets and forms. The whole nursing home works together-everyone has their own duties, but they overlap."

The library they use in VistaKEANE Care Plan was developed over years. It includes for example, problem statements that cover all ADLs, one for totally dependent residents and one for residents who need some assistance. The problem statement for those who need assistance is individualized to specify the help and level needed.

Rockville Nursing Home uses the software to personalize the care plan, print it, and keep it updated.

• Focus on Care Plan

• VistaKEANE and the Care Planning Process

How Can I Find Out More About Care Plan?