Comprehensive Care Plan Process Flashcards

A facility's policy states care plans are updated 'as needed.' A surveyor would find this policy deficient primarily because:

Answer: Regulations mandate minimum review frequencies that cannot be replaced by discretionary language

Federal rules require quarterly review at minimum; a policy permitting updates only 'as needed' creates a gap where mandatory reviews could be skipped.

A resident with dementia is assessed as having high fall risk but refuses to use a bed alarm or call light. The care plan should:

Answer: Document refusal, offer alternatives, and include all feasible interventions the resident will accept

Even when a resident refuses specific interventions, the facility must document the refusal, provide education, and implement all other feasible safety measures.

Which scenario best demonstrates a systemic care planning deficiency versus an isolated individual deficiency?

Answer: Multiple residents' care plans lack psychosocial goals despite documented depression diagnoses

A pattern of missing psychosocial goals across multiple residents with identified depression indicates a systemic failure rather than an isolated error.

Under the OBRA framework, which document provides the foundation for identifying care planning 'triggers' that require further assessment?

Answer: The Care Area Assessment (CAA) process initiated by MDS triggers

The CAA process, triggered by specific MDS items, guides the interdisciplinary team in deciding which areas to address in the care plan.

A resident's care plan goal reads: 'Resident will express satisfaction with meal choices by next review.' This goal is problematic because:

Answer: It lacks a measurable baseline or criterion for success

Without a measurable criterion (e.g., 'rates meals ≥7/10 on satisfaction scale'), progress toward this goal cannot be objectively evaluated.

A surveyor observes that the care plan room is locked and staff must request access from the charge nurse to review care plans. The concern with this practice is:

Answer: Restricted access may prevent timely implementation of care plan interventions by all staff

If care plans are not readily accessible to all direct care staff, timely and consistent implementation of interventions is compromised.

A resident's care plan was developed and signed 90 days ago but has not been reviewed since. The resident recently developed a urinary tract infection that resolved two weeks ago. Is a care plan revision required?

Answer: Yes if the infection caused a significant change; otherwise the quarterly review is sufficient

A resolved, uncomplicated UTI is unlikely to constitute a significant change requiring an unscheduled revision, but it should be addressed at the next quarterly review.