CIHQ-ARS Blog

Nursing care plans…that annoying task that many of us consider an unimportant chore – and one of those requirements that you must complete when a patient is admitted. Think back to why you do a care plan for the patient. The nursing plan of care is based on the nursing assessment and formation of a nursing diagnosis. Registered nurses plan and implement care and then evaluate the patient’s outcomes. Key word: A registered nurse is required to develop the plan. The licensed practical or vocational nurse can have input, but the actual assessment and plan is developed by a registered nurse. Surveyors will look to see that the patient was assessed, and a care plan developed by a registered nurse. The plan is adjusted to continue to reflect the patient’s care. Sounds easy enough…so why are care plans such a prevalent finding during accreditation surveys? Let us see what is frequently cited and how you can avoid those pitfalls.

The CMS regulations at §482.23(b)(4) guide the development of a care plan. It reads like this: The hospital must ensure that the nursing staff develops and keeps current a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. The interpretive guidelines states that the care plan be developed in response to the nursing care needs (not just the medical diagnosis) and is kept current by ongoing assessment of the patient, the patient’s goals, and response to interventions.

What is the purpose of the plan? It is a tool for collaboration between disciplines, a communication tool, and a way to defend and provide a record of care that shows care standards were adhered to in case of lawsuits or patient complaints. The nursing plan of care can be a part of a multi-disciplinary plan of care or can stand on its own. Many organizations have opted for care plans either built into the electronic health record (EHR) or use of preprinted forms which allow for staff to select a nursing diagnosis based on their assessments, then choose interventions and expected outcomes. Some EHRs even trigger staff to select a plan of care based on orders entered or diagnosis. Be careful with these. Technology may be a time-saving way to write the care plan, but technology does not assess the patient. Therein lies a problem. Be cautious about selecting all interventions available under a nursing diagnosis. Make sure that you select only those that apply to your patient. One notable example is a patient with an amputation. If an intervention on the care plan is to assess the patient’s pedal pulses, and staff acknowledge that they are completing this intervention – it is difficult to defend your documentation when the patient does not have a lower extremity. While technology can suggest interventions, they may not be appropriate for your patient. That takes critical thinking.

Remember to update the care plan based on the patient’s current condition. Consider this: The 75-year-old patient that is admitted with a diagnosis of pneumonia, is currently alert, febrile but otherwise stable vital signs, and only requires oxygen support and antibiotics. The nursing care plan identifies ineffective airway clearance, risk of falls, knowledge deficit, and discharge planning needs. Interventions may include measurement of vital signs and oxygen saturation, encouraging coughing and spirometry, ambulation, fall risk precautions, teach-back education regarding disease process and medications. Goals are to encourage ambulation, prevent falls, maintain oxygenation, verbalize importance of fluid intake, coughing, and medication side-effects to report, and a long-term goal of discharge to home. Several days later, the patient deteriorates and requires intubation, sedation, and mechanical ventilation. If the plan of care is not updated to reflect the patient’s current status, you could risk a citation. If you are still documenting that you are encouraging ambulation and oral fluid intake, the patient is verbalizing understanding, and you have not updated the discharge goals, your documentation puts you at risk for a citation during a survey, and scrutiny if there were ever legal proceedings.

There are a few things that are always required to be added to a patient’s nursing care plan. CMS requires that if restraints are in use, it must be reflected in the patient’s plan of care. This applies to all locations where restraints are used, even in the emergency department. It is the only POC that is required to be written in the ED. Another is fall risk. If the patient is at risk for falls, there should be a plan that addresses how to prevent falls. If a patient is identified as a nutritional risk, a plan of care (in collaboration with the dietitian) must be developed and implemented. During accreditation surveys, the most frequently cited areas of care plans are:

• Care plan is not present – or not initiated until several days after admission
• There is no evidence that the patient or patient’s representative participated in the development of the plan of care
• The care plan does not reflect the current needs of the patient
• Restraints are/were in use and there was no care plan for the use of restraints
• Interventions and goals are not updated to reflect the current assessment of the patient
• Continuing to acknowledge and make daily entries on a plan that is outdated and not consistent with the current patient status or when the goal has already been achieved.
• If an interdisciplinary plan is used, nursing input must be clearly reflected in the plan.
• Last, for hospitals with swing beds, the care plan must include services needed to attain the highest practicable physical, mental, and psychosocial well-being.

References
Center for Improvement in Healthcare Quality (2022). Accreditation Standards for Hospitals.
Centers for Medicare and Medicaid Services (2020). State Operations Manual, Appendix A – Survey Protocol, Regulations, and Interpretive Guidelines for Hospitals. §482.23(b)(4)
Nightingale College. Nursing care plans from A to Z: A complete guide for registered nurses.