Writing Care Plan Problem Statements

The 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 theMDS 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 orCare 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 

ADA Says Expand Dental Care for Nursing Home Residents

Over one million nursing home residents face barriers to accessing adequate dental care, according to a recent policy statement by the American Dental Association, Action for Dental Health.

Presently, long term care facilities must cover the cost of dental care for residents.

The ADA recommends expanding the public health system to cover the cost of dental care for long term care facility residents. 

Action for Dental Health 

Dental Care and Nursing Care Plans

Coding Section L of the MDS 3.0, Dental Care

Resident-to-Staff Aggression is a Common Problem

Resident verbal and physical aggression is most common during morning care, says a recent article in the Journal of General Internal Medicine.

The article concludes that since resident-to- staff aggression has such a negative impact on job performance and staff satisfaction, much more research is needed to develop interventions to decrease resident aggression. 

Verbal and Physical Aggression Directed at Nursing Home Staff by Residents

Behavior Care Plans 

Anger Care Plan

Online Nursing Assistant Behavior Inservice 

Coding Section E, Behavior

Urinary Incontinence is Costly to Health and Finances

Although the prevalence of urinary incontinence is 51% among women and 14% among men, it is significantly under-reported by patients and under-diagnosed by clinicians, according to a recent article by Home Healthcare Nurse. 

Financial costs for women older than 65 years of age are $7.6 billion per year. 

Urinary incontinence is also very costly to health. It is a frequent cause of falls in older adults, related to hurrying to try to get to the bathroom in time. 

Physical results of urinary incontinence often include pressure sores, urinary tract infections, institutionalization, depression, isolation, and decreased mobility. 

Identifying Urinary Incontinence in the Home Setting – Home Healthcare Nurse 

Facility Program for Urinary Incontinence 

Restorative Programs for Urinary Incontinence

Nursing Care Plans for Urinary Incontinence 

Online CNA Inservice for Toileting and Elimination

Abuse Prevalence in Long Term Care

The statistics will shock you. During 1999-2001, nearly 1 in 3 U.S. nursing homes were cited for violations that had potential to cause harm or that had caused actual harm to a resident.  

Educating staff members on abuse prevention is more important than ever, and should always be part of yearly inservice training.  

UC Irvine’s Center of Excellence on Elder Abuse and Neglecthas some great resources for abuse education, and is the world’s first Elder Abuse Forensic Center, bringing together physicians, psychologists, law enforcement, social workers and others to handle complex cases.  

The center hosts the Elder Abuse Training Institute which identifies the most pressing training needs in elder mistreatment, and was recently named by the U.S. Administration on Aging as the National Center on Elder Abuse.  

Download their printable brochure Abuse of Residents of Long Term Care Facilities and read detailed facts and statistics about elder abuse.  

Check out this comprehensive and affordable online inservice for Preventing Resident Abuse . 

Care Plans and Preventing Avoidable Declines

Surveyors will investigate if the resident declined or failed to improve relative to expectations, and determine if this was avoidable or unavoidable.
The Care Plan is a record that describes the resident’s functional abilities at different times of the past year. Make sure the documentation is comprehensive and genuinely reflects the resident’s abilities. If the goals are realistic and regularly measured, it will help to identify declines.
Surveyors will focus on the Late-loss ADLs, those considered to be the last to decline or deteriorate: Bed Mobility, Transfer, Eating, and Toilet Use. They will use the Quality Indicators and the Quality Measures, and evaluate occurrences and preventative measures.
The Admission Assessment and Care Plan should accurately document the resident’s mobility, range of motion, transfer ability, and balance. Evaluations from Physical Therapy, Occupational Therapy, and Restorative Nursing will give in-depth information about the resident’s level of functioning.

Nursing Care Plans and CAA Documentation

The goal in documenting the Care Area Assessment process is to identify what needs to be care-planned, and why or why not. The documentation should include the problem, contributing and risk factors, and state if improvement is possible or decline can be minimized. 

CAA Summary notes should be brief but cover the essential points. Documentation for each triggered CAA should generally describe:

 Nature of the issue or condition (may include presence or lack of objective data and subjective complaints).

Complications and risk factors that affect the staff’s decision to proceed to care planning. 

Factors that must be considered in developing individualized care plan interventions. Include appropriate documentation to justify the decision to care plan or not to care plan for the individual resident. 

Need for referrals or further evaluation by appropriate health professionals. 

Written documentation of the CAA findings and decision-making process may appear anywhere in the resident’s record. 

The documentation can be located anywhere in the resident’s chart, and any form of CAT Summary Note is acceptable. 

It can be written in discipline specific flow sheets, progress notes, in the care plan summary notes, in a CAA summary narrative, on a CAA questionnaire, etc.

No matter where the information is recorded, use the “Location and Date of CAA Assessment Documentation” column on the CAA Summary form to note where the CAA review and decision-making documentation can be found in the resident’s record.  Also indicate in the column “Care Plan Decision” if the triggered problem is addressed in the care plan.

Refer to the location and date of this documentation on the CAA Summary Form, which is section V of the MDS. 

Using the right CAA Modules in this manual will make the process much easier.

Care Area Assessment Book with Triggers and Modules

CAA Nutritional Status

CAA Cognitive Loss – Dementia