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No, but the information can be given to the
primary physician and he can determine if there is a an acute illness or if this
is a progression on the disease process and does document the same.
This response is contrary to
CMS policy in cases in which the resident has a terminal condition.
See page 2-11 of the RAI User's Manual. Just because a new MDS is not
required does not relieve the facility of the responsibility to ensure that
the care plan is appropriate at all times.
However, in the case
described by the questioner, the resident apparently does not have a
terminal condition. It would not be up to the nurse to determine
whether the decline is an expected part of the course of the disease
process.
Rena
Rena R. Shephard, MHA, RN, FACDONA,
RAC-C
Chair, American Association of Nurse Assessment
Coordinators
[EMAIL PROTECTED]
Subj: RE: Expected Decline
Date: 3/6/04 3:07:34
PM Pacific Standard Time
From: [EMAIL PROTECTED]
Reply-to: [EMAIL PROTECTED]
To: [EMAIL PROTECTED]
Sent from the
Internet
if the mds is supposed to
reflect the resident then i would still do a sig change when the mds no
longer reflects the patient status, i was hoping to use this to help
stop some of the paper work , if the decline is expected we still have
to do something to keep the resident comfortable, out of pain, maintain
skin integrity etc
-----Original Message-----
From:
[EMAIL PROTECTED] [mailto:[EMAIL PROTECTED]On Behalf Of
[EMAIL PROTECTED]
Sent: Thursday, March 04, 2004
6:22 AM
To: [EMAIL PROTECTED]
Subject: Expected
Decline
If a decline is expected in resident’s
condition, how much and what type of documentation is needed in the
RAPS, so that a significant change in condition assessment will not
be necessary in the future? I have struggled with this in the
past and now I have a resident with a new hip fracture (2nd fx in 9
months) not eating (has had a history of poor eating habits and
thought to be anorexic although never documented as so by doctor),
my nursing judgement tells me he will continue to decline which
leads me back to my original question. Thanks in
advance.
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