Journal of Gerontological Nursing

CARE PLANNING for Nursing Home Residents: Incorporating the Minimum Data Set Requirements Into Practice

Roma Lee Taunton, PhD, RN, FAAN; Daniel L Swagerty, MD, MPH; Barbara Smith, PhD, MHSA, RN; Joyce A Lasseter, PhD, RN, CCRN; Robert H Lee, PhD

Abstract

ABSTRACT

This study was designed to describe the care-planning process used in nursing homes and identify links among care planning, care provided, and the Resident Assessment Instrument and Minimum Data Set (MDS). Study participants in three Midwestern nursing homes included residents and family members, MDS coordinators, direct care staff, administrators, directors of nursing, and medical directors. Data were collected via semi-structured interview, observation, and resident record audit. The care-planning process differed among the three facilities despite the common MDS system structure. Care planning and the MDS system were linked to the care provided to residents through documentation in residents' records, translation of the MDS care plan to the documents used for daily care, and ongoing communication through end-of-shift report and other venues.

Abstract

ABSTRACT

This study was designed to describe the care-planning process used in nursing homes and identify links among care planning, care provided, and the Resident Assessment Instrument and Minimum Data Set (MDS). Study participants in three Midwestern nursing homes included residents and family members, MDS coordinators, direct care staff, administrators, directors of nursing, and medical directors. Data were collected via semi-structured interview, observation, and resident record audit. The care-planning process differed among the three facilities despite the common MDS system structure. Care planning and the MDS system were linked to the care provided to residents through documentation in residents' records, translation of the MDS care plan to the documents used for daily care, and ongoing communication through end-of-shift report and other venues.

Nursing home residents are vulnerable, and their needs are complex. Maintaining and improving the quality of care is critical to their well-being. The federally mandated Long Term Care Facility Resident Assessment Instrument (Health Care Financing Administration [HCFA], 1995) provides standardized protocols for resident assessment and care planning as well as a minimum data set to facilitate quality improvement within and across facilities. However, little is known about the ways in which nursing facilities incorporate these standardized tools into the nursing process. Comprehensive, reliable descriptions of care planning and delivery in nursing facilities are needed to understand how to sustain improvements in care. However, such descriptions are lacking in the literature.

The study described in this article examined care planning and delivery in three Midwestern nursing facilities. Study findings are reported in this article as well as in two companion articles (Swagerty, Lee, Smith, & Taunton, in press; Taunton, Swagerty, Lasseter, & Lee, in press.). Two specific aims guided the component of the study reported in this article:

* To describe the care-planning process used by nursing facilities.

* To identify the links among care planning, the care provided, and the federally mandated Resident Assessment Instrument and Minimum Data Set (MDS) (HCFA, 1995).

METHODS

Three nursing facilities participated in the project, which was guided by a qualitative emergent case study design. Purposive sampling accounted for variation among nursing facilities on location, ownership, size, and type of nursing units. Data were collected by direct observation, interview, and chart abstraction at each facility during a 3-month period.

To facilitate across-facility comparison on a common clinical problem, the resident sample was limited to intermediate care residents who were incontinent. The staff sample encompassed nursing personnel and other staff who participated in assessment, care planning, or care delivery for the designated residents. In addition, administrators, directors of nursing, and medical directors were interviewed.

Setting

Facility 1 was part of a private, non-profit chain located in the Midwest. The facility included 34 assisted living units and 134 nursing care beds that were allocated among 5 resident care units. One unit was designated for ambulatory residents with early Alzheimer's disease or dementia, and another for residents with advanced Alzheimer's disease or dementia who were not ambulatory. All beds were certified for Medicare so that residents could receive skilled care in their regularly assigned rooms. On average, six to eight Medicare residents were scattered across multiple units.

Facility 2 was a countyowned facility that had recently expanded capacity from 48 to 60 beds. The facility operated as a single unit, with 48 to 50 residents residing in the facility at the time of data collection.

Facility 3 was part of a national for-profit chain. Each of 2 resident care units accommodated 41 residents, with 12 beds on one unit certified for Medicare.

Sample

Residents at each facility were selected to represent various types of assessment: new admission, quarterly, or annual. In Facilities 1 and 3, residents were drawn from all units. Residents were eligible to participate if they were incontinent and were scheduled for an MDS assessment within target dates. In addition, a caretaking family member or significant other had to agree to be interviewed or arrange an interview with another family member or friend as well as to consent to the resident's participation.

Seventeen residents who met these requirements (n = 6 for Facility 1, n = 6 for Facility 2, and n = 5 for Facility 3) participated in the study. The majority were women and ranged in age from 67 to 99 years. Approximately 60% had private insurance or were self-pay; the remaining residents were supported by Medicaid.

Except for one spouse who died before an interview could be scheduled, all of the invited family members or friends participated. Residents' significant others (n = 16) included 6 daughters, 3 sons, 3 sisters-in-law, 1 niece, and 3 friends.

Staff participants (n = 75) were selected at each facility based on their participation in the formal care-planning process, management role, or direct care responsibility for the participating resident subjects. Included were nursing staff, social service staff, activity staff, dietary supervisors, restorative aides, rehabilitation staff, directors of nursing, administrators, and medical directors (Table 1). Tenure of staff participants at their current facility ranged from 2 months to 31 years.

Table

TABLE 1STAFF SAMPLE FOR THE STUDY FACILITIES

TABLE 1

STAFF SAMPLE FOR THE STUDY FACILITIES

Procedure

Approval of the study was obtained from the University of Kansas Medical Center Human Subjects Committee. Residents who met the selection criteria were identify by designated contacts (e.g., director of nursing, MDS coordinator) at each facility. Written consent was obtained from caretakers or guardians for resident participation prior to data collection. Residents who had adequate cognitive function also consented verbally. Resident family members and friends as well as staff gave written consent prior to tape-recorded interviews.

Data collection began at each facility by observing the MDS coordinator. For resident participants, careplanning meetings were observed first, and then 4 to 6 weeks later, residents' care was observed for a total of 12 hours during a period of 2 or more days. Residents were interviewed at some point during observation, and significant others were interviewed after resident observations were completed. Staff interviews were conducted last, and most staff were interviewed in groups of two to four. In addition to the care-planning meetings, other regularly scheduled staff meetings in which decisions were made about residents' care also were observed.

Data related to incontinence were abstracted from residents' medical records for the 2-week period prior to MDS assessment to determine consistency between the recorded information and the assessment. Data also were abstracted for the observation period to determine consistency between the care plan related to incontinence and the care delivered, and between research staff observations and documentation in the record.

Data Analysis

Case reports were generated sequentially for each of the three facilities. Beginning with Facility 1, project staff derived a basic set of codes using a representative sample of the data. The codes were applied to the data set using NUD.IST (Qualitative Solutions & Research Pty Ltd., Melbourne, Victoria, Australia) software. To maintain coding reliability, groups of three project staff coded and reviewed designated segments of the data together until the coding was completed. All data assigned under the respective codes were printed and reviewed for categories and themes.

As a member check, narrative statements of findings around core concepts were submitted to several groups of facility staff for feedback and clarification. A certified gerontological nurse practitioner experienced in nursing facilities and qualitative research examined a representative sample of the data from each facility for fit to the coding protocol and provided input to the synthesis of findings. This process was repeated using the data collected for Facilities 2 and 3.

Table

TABLE 2PARTICIPATING TEAM MEMBERS AND SOURCES OF INFORMATION FOR RESIDENT ASSESSMENT AT THE STUDY FACILITIES

TABLE 2

PARTICIPATING TEAM MEMBERS AND SOURCES OF INFORMATION FOR RESIDENT ASSESSMENT AT THE STUDY FACILITIES

Cross-case analyses were based on the respective facility findings and reports. Individual research team members summarized findings across facilities related to assigned core concepts using appropriate matrices to facilitate the identification of similarities and differences. Findings related to the process for planning resident care were organized in a 2 × 3 matrix. The full team discussed and modified the matrices.

RESULTS AND DISCUSSION

Care-Planning Process

Findings related to the care-planning process used by nursing facilities addressed the composition of the team and responsibilities of respective members, sources of information for the MDS assessment, the sequence of events for care planning, and issues related to resident assessment and care planning.

MDS assessment. Several similarities emerged across the three facilities in regard to resident assessment. Assessment and care planning were centralized under a single MDS coordinator. The MDS system drove the content and scheduling of resident assessment and care-plan review. Long-term residents were assessed at admission and reassessed at 30 and 90 days, then quarterly, and annually thereafter. Residents also were reassessed when a significant change occurred that persisted for 2 weeks and following any hospitalization.

The schedule for care-plan review was available a month in advance, and the MDS coordinator initiated the assessment I to 2 weeks before the date for care-plan review. Other staff assisted the coordinator by completing parts of the assessment. Direct care staff reported changes in residents to the MDS coordinator on an ongoing basis.

Table

TABLE 3SEQUENCE OF EVENTS BEFORE CARE PLAN MEETINGS FOR DESIGNATED RESIDENTS AT THE STUDY FACILITIES

TABLE 3

SEQUENCE OF EVENTS BEFORE CARE PLAN MEETINGS FOR DESIGNATED RESIDENTS AT THE STUDY FACILITIES

The composition of the team responsible for assessment and the sources of information used by the MDS coordinators differed across faculties (Table 2). Variations related to the participation of dietary, activity, and restorative staff; reliance of the coordinator on verbal input from key direct care staff; direct appraisal of residents by the coordinator; and sources of documentation other than residents' records.

In all three facilities, communication with or referral to a physician were common outcomes of resident care-plan review. In contrast to the 19% Institute of Medicine report that some nurses who complete MDS assessments may never see the residents in question (Wunderlich, Sloan, & Davis, 1996), all of the MDS coordinators in this study knew the residents well and had similar perceptions of residents as other staff. The Facility 3 coordinator had the most direct contact with residents during assessment.

Developing and revising the formal MDS system care plan. Care planning was similar in several ways among the three faculties. The MDS coordinator led care planning. The process was based on MDS assessment and the Resident Assessment Protocols (RAPs) that triggered more in-depth evaluation of emerging problems. Formal MDS system care plans were filed in residents' charts and translated to other documents used to guide and record daily care (e.g., medication, activities of daily living [ADL], and certified nursing assistant assignment sheets).

Family input also was valued. Family members were contacted about the care-planning conference for their residents and were provided alternatives for input when unable to attend. Staff presented absent family members' viewpoints and concerns. At Facilities 1 and 2, resident input to the conference came indirectly through family members or staff, particularly the social worker. Some Facility 3 residents came to the careplanning meeting with their respective family members.

There also were substantial differences in the care-planning process among the three facilities (Tables 3 and 4). The timing of specific steps in the sequential process varied, as did the focus of the official care-planning meeting. At Facility 1, the RAPs and care plans were completed during care-planning meetings. Initially, meetings seemed chaotic to the observers, with multiple activities and conversations happening simultaneously. However, after observing for a while, the observers began to see that the process was systematic and the group was thorough and efficient.

Table

TABLE 4SEQUENCE OF EVENTS DURING CARE PLAN MEETINGS FOR DESIGNATED RESIDENTS AT THE STUDY FACILITIES

TABLE 4

SEQUENCE OF EVENTS DURING CARE PLAN MEETINGS FOR DESIGNATED RESIDENTS AT THE STUDY FACILITIES

Meetings at Facility 2 were more formal. The team reviewed the already completed RAPs and developed the plan. The MDS coordinator, who was the director of nursing, consistently used the meeting as a teaching opportunity with team members. The team identified needs among the direct care staff for individual counseling or inservice related to specific residents.

At Facility 3, care plans were completed and printed prior to meetings, which were used for discussion with residents and family members. Changes were handwritten as needed.

There was tension regarding a role for certified nursing assistants in care planning. A Facility 1 certified nursing assistant remarked that they should be included in the care-planning meeting because they provided direct care for residents. Several Facility 2 certified nursing assistants felt left out of the care-planning process. Despite observations that changes in the care plan were communicated to the nursing assistants verbally by the charge nurses, some did not perceive they were getting feedback about care planning from the licensed staff. Most of the Facility 2 certified nursing assistants had long tenure with the facility, and they remembered a different time. The Omnibus Budget Reconciliation Act of 1987 led nursing facilities to hire more licensed nurses. As a result, the most experienced and most invested employees at Faculty 2 lost authority as well as routine participation in careplanning conferences. Most of the Facility 3 certified nursing assistants could articulate their role in the careplanning process, and few seemed to think a more extensive role was needed.

Ongoing care planning. In addition to the formal cyclical MDS system, assessment and care planning were dynamic components of the daily care provided to residents. At Facilities 1 and 2, the care-planning teams ended their regular meetings by talking about problems with specific residents who were not scheduled for review that day. Charge nurses and staff managed emerging resident problems through temporary protocols, daily care documents, and Postit notes. Once formal MDS care plans were completed and placed in residents' records, there were no additions or deletions until the next quarterly update unless a change in a resident's condition persisted for the 2 weeks required to trigger an unscheduled reassessment.

Table

TABLE 5DOCUMENTATION, COMMUNICATION, AND TRANSLATION RELATED TO RESIDENTS' MDS ASSESSMENTS AND CARE PLANS AT THE STUDY FACILITIES

TABLE 5

DOCUMENTATION, COMMUNICATION, AND TRANSLATION RELATED TO RESIDENTS' MDS ASSESSMENTS AND CARE PLANS AT THE STUDY FACILITIES

At Facility 3, licensed staff added residents' emerging problems and interventions to the formal care plan in the residents' records. The MDS coordinator updated residents' care plans in the computer as telephone orders from physicians were received and processed. Weekly resident status meetings also were held. Residents with wound, weight, or skin problems were the continuing focus of the meetings, but all residents were reviewed once a month. The MDS coordinator generated an updated information sheet about the designated residents to facilitate review and discussion. The director of nursing conducted the meeting, which was attended by charge nurses, the director of rehabilitation services, and the care-planning team. Many decisions were made about care during resident status meetings.

Weekly Medicare meetings also were held at Facility 3. These meetings were conducted by the charge nurse from the unit with Medicare residents. Participants included all rehabilitation staff, the care-planning team, and the director of nursing. The group reviewed all Medicare residents from the perspective of goals for care within the funded service period. Any need for supplemental funding for residents was identified early to facilitate transition without disruption of care. The charge nurse documented progress and changes in care in residents' records. New or continuing issues with non-Medicare residents were discussed at the end of meetings.

Links Among Care Planning, Care Provided, and MDS System

At each facility, current MDS assessments and care plans were filed in residents' records. Considerable documentation, translation, and communication occurred related to residents' assessments and care plans (Table 5). The current month's medication, treatment, and ADL sheets for all residents were maintained in separate notebooks for easy access by the specific nursing staff who used them; those documents were filed in residents' records at the end of the month.

Staff used residents' medication, treatment, and ADL sheets to guide as well as document daily care. An assignment sheet for certified nursing assistants also guided daily care. Monitoring information related to nutrition and special resident problems such as pressure ulcers was kept in special notebooks.

Documentation

For this study, urinary incontinence was used as a clinical probe to examine consistency between residents' current MDS assessments and the information documented in residents' records during the preceding 2 weeks. Data also were abstracted from residents' records for the observation period to determine consistency between the care plan and the care delivered, and between research staff observations and documentation in the record.

Limited documentation of incontinence evaluation or care was found at Facility 1. For one resident, a recent assessment and treatment for a urinary tract infection was not captured in the MDS assessment. On the days care was observed, the ADL flow sheet section on continence was completed for three of the six residents. For two residents, continence status on the flow sheet was not the same as that observed by research staff.

At Facility 2, there was more documentation of incontinence evaluation and care. Documentation was found on the ADL flow sheet to support the assessment for five of the six residents. There were relevant physician progress notes and laboratory reports for two residents. Three residents had RAPs for incontinence that were generally consistent with documented information.

At Facility 3, there were few issues about documentation for the five residents. One resident who was marked incontinent on the recent MDS assessment was continent during the observation period; staff explained this resident was not always incontinent.

Communication and Translation

All of the care-planning teams made changes that were communicated to staff and implemented by staff. After MDS assessment and care-plan review, changes in care plans were communicated to charge nurses, who translated the relevant elements to the documents that guided daily care.

Verbal communication was preferred across facilities, particularly by the certified nursing assistants. Endof-shift reports were a primary vehicle for transmitting information about residents and care plans, but the procedure for these reports varied considerably within and between facilities.

Staff attitudes about the documents that connected resident assessment and care planning to delivery of care varied. At Facility 1, registered nurses discounted the MDS system because it summarized what they had been doing; they did not acknowledge that it added any value for residents. Other staff also discounted the formal care plan. A certified nursing assistant remarked:

Sometimes I go with the care plan when I'm told about it, and sometimes I say, "Well, that does not work for that particular resident." The nurses are more likely to have to go by what the certified nursing assistants say because we're the ones who are oneon-one with the resident.

Although Facility 2 certified nursing assistants had mixed opinions about the value of their daily care plan, the director of nursing emphasized the assistants' daily care plans. She noted that it was the responsibility of each assistant to use the sheets and that she looked at the sheets, but added that the aides could change the sheets.

A Facility 3 certified nursing assistant said:

I'm ashamed to admit that I don't look at them [daily care plans] as often as I should because I am so used to the residents, and I know basically what they will or won't do.

A licensed practical nurse commented:

Maybe some of the forms could be changed around because some of them are so long, but I think we need the [MDS] care plans. I go back and look at them and see what we can do, and also they let us know if the resident is deteriorating or if they are improving.

In each facility, skepticism among various types of staff about the formal MDS care plan combined with nursing assistants' reluctance to use the daily care plans or assignment sheets to disrupt connections among the formal documents and the delivery of care. Facility 2 nursing assistants who ignored daily care plans missed an opportunity to give input to the formal MDS care plan. At Facility 3, the requirement that nursing assistants sign the resident status sheet on each shift may have encouraged them to use the sheet for information.

Minimum Data Set Feedback

The state benchmarking reports were in the early stages of development during the data collection period for this study. None of the facilities were using them as yet for quality improvement, and there was concern about inaccuracies. For example, a Facility 1 report indicated 100% of their residents were incontinent.

Overall, few feedback mechanisms were available related to either individual or organizational performance. Important sources of feedback to individual staff included self, residents, and other staff. In contrast to Faculties 1 and 3, Facility 2 did not use an annual performance review.

IMPLICATIONS FOR NURSING PRACTICE

The small sample prohibits generalization of the findings of this study to other nursing facilities. Nevertheless, the study reveals a great deal about resident assessment and care planning. The MDS system is not a paper process unrelated to real events in the facilities examined; it results in real changes in the care that residents receive. In addition, it absorbs extensive resources.

Although the approach differs among facilities, the AIDS technology is central to the care-plamiing process in each facility. Formal and informal elements of ongoing care complement the MDS system. Facility 3 demonstrates that die MDS system can be integrated seamlessly into daily operations and an accurate fit can be maintained between the formal care plan and documents that guide daily care. Updating residents' formal care plans to incorporate changes in care that are initiated during regularly scheduled direct care staff meetings (e.g., resident status and Medicare meetings at Facility 3) keeps the plans current, thereby reducing the need for updating during the quarterly care-plan review. Updating by direct care staff also increases their ownership of the care-planning process.

The variations in the structure of the MDS coordinator role raise compelling questions. Facility financial survival requires timely submission of resident assessment data that accurately reflect the complexity of resident care. Facility 1 has abandoned an earlier model in which direct care staff on the units assumed responsibility for the MDS system but could not maintain the schedule required to meet the federal guidelines.

Although limiting the coordinator's responsibilities to the MDS system makes it possible for one individual to assume the resident assessment and care-planning function across several units, the absence of involvement in direct care isolates the MDS coordinator from direct care staff to some degree. The multitasking approaches used in Facilities 2 and 3 gain efficiency and integration of the MDS system, enhance the credibility of the care-planning process, improve documentation, and provide follow up to assure implementation of care plans.

The complexity of resident assessment and care planning through the MDS system increases with the number of residents in the facility. In larger facilities, having a single MDS coordinator across all units may not be feasible or desirable, and direct involvement of the director of nursing in the MDS system may be constrained. Structuring the nurse manager role to incorporate MDS coordinator responsibilities can be a viable approach, given sufficient support for both care plarining and other functions. With multiple MDS coordinators, a specific mechanism will be needed to facilitate reliable application of the definitions and guidelines.

The composition of the team responsible for resident assessment and care planning also is important. Including activity, dietary, and restorative staff enriches the information base brought from nursing and social service and may raise awareness in those departments of residents' needs. A more visible role for certified nursing assistants could be instrumental in gaining acceptance of the process within that group. In addition, having rehabilitation staff contribute to the ongoing care of all residents facilitates greater integration of restorative principles.

The findings of this study indicate that implementation of changes in residents' care plans outside the "routine" are hard to sustain. Participation of various types of staff in the formal care-planning process increases the likelihood of appropriate interpretation of the need and support for the elements of care in the designated departments.

Participation of residents and family members in the care-planning process varies in the facilities in this study. Facility 3 is more aggressive in obtaining input from family members who cannot attend care-planning meetings and also include residents in the meetings. Family members and residents who come to the meetings regard it as a forum to have their concerns heard and addressed. Generally, residents may be reluctant, or unable, to report poor or inappropriate care. Empowering the advocacy of family members and significant others is essential if care in a facility is to be improved and the improvements sustained.

Facility 2 is unusual in regard to the long tenure and cross training of many certified nursing assistants as medication and restorative aides, and for one or two, as a social work designee. A more resident-focused care delivery model could take maximum advantage of their expertise. For example, an adaptation of partnership nursing could be structured in which certified nursing assistants with multiple skills are assigned continuously to a specific group of residents, provide comprehensive care to meet their needs, and provide input about the designated residents to the care-planning team. Partnerships would include licensed staff for supervision and less skilled certified nursing assistants for help with residents' physical care.

The preference of staff for informal communication and the resistance of certified nursing assistants to written media may threaten the nursing process in long-tem care facilities. A significant number of the staff believe they know what to do without care plans, assignment guides, or even end-of-shift reports. The translation of the MDS care plan into the documents that guide daily care is the most likely place for disconnects in the system. More research is needed about information that may be lost and about communication tools that are effective in reaching direct care staff.

Both leaders and direct care staff need ongoing feedback about their performance. Schnelle et al. (1993, 1995) advocate a reasonable approach to performance monitoring and process improvement. The challenge is to develop a system of performance measurement that lays a foundation for improvement efforts, incorporates the benchmarking available from state and federal reports, sidesteps the resistance of staff to paperwork, and does not exhaust the staff or the budget.

REFERENCES

  • Health Care Financing Administration. (1995). Long-term care facility resident assessment instrument (RAI) user's manual for use with version 2.0 of the Health Care Financing Administration's Minimum Data Set, resident assessment protocols, and utilization guidelines. Baltimore, MD: Health Care Financing Administration.
  • Schnelle, J.F., McNees, M.P., Crooks, V., & Ouslander, J.G. (1995). The use of a computer-based model to implement an incontinence management program. The Gerontologut, 35, 656-665.
  • Schnelle, J.F., Newman, D., White, M., Abbey, J., Wallston, K.A., Fogarty, T., & Dry, M.G. (1993). Maintaining continence in nursing facility residents through the application of industrial quality control. The Gerontologist, 33, 114-121.
  • Swagerty, D.L., Lee, R.H., Smith, B., & Taunton, R.L. (in press). The context for nursing home resident care. Journal of Gerontological Nursing.
  • Taunton, R.L., Swagerty, D.L., Lasseter, J.A., & Lee, R.H. (in press). Continent or incontinent? That's the question. Journal of Gerontological Nursing.
  • Wunderlich, G.S., Sloan, RA., & Davis, CK. (Eds.). (19%). Nursing staff in hospitals and nursing facilities. Is it adequate? Washington, DC: National Academy Press.

TABLE 1

STAFF SAMPLE FOR THE STUDY FACILITIES

TABLE 2

PARTICIPATING TEAM MEMBERS AND SOURCES OF INFORMATION FOR RESIDENT ASSESSMENT AT THE STUDY FACILITIES

TABLE 3

SEQUENCE OF EVENTS BEFORE CARE PLAN MEETINGS FOR DESIGNATED RESIDENTS AT THE STUDY FACILITIES

TABLE 4

SEQUENCE OF EVENTS DURING CARE PLAN MEETINGS FOR DESIGNATED RESIDENTS AT THE STUDY FACILITIES

TABLE 5

DOCUMENTATION, COMMUNICATION, AND TRANSLATION RELATED TO RESIDENTS' MDS ASSESSMENTS AND CARE PLANS AT THE STUDY FACILITIES

10.3928/0098-9134-20041201-09

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