Assessments and Care Planning
Every person in a nursing home has a right to good quality care under the Federal Nursing Home Reform Act of 1987. To provide good quality care, nursing homes must assess and plan for each resident. Care plans are essential to provide nursing home residents with good quality care.
Nursing Home Resident Assessments
Nursing homes must assess each resident in order to meet his or her needs. An Assessment should include the following:
- Life history, daily routine, strengths, interests, food preferences, and other personal information;
- Functional abilities including walking, dressing, using the toilet and eating;
- Physical or mental conditions that affect a resident;
- Potential for improvement;
- Communication abilities;
- Nutritional status and medications.
Assessments are required to be done within 14 days of the resident’s admission to a nursing home (or 7 days for Medicare residents). Assessments are also required to be done every three months and when a resident’s condition changes according to federal nursing home law.
Nursing Homes Prepare Care Plans
After assessments are completed, and “problem areas” are identified, a care plan is developed to address all the needs of the resident. The care plan identifies what treatment, care and medications are necessary as well as which nursing home staff will be responsible to provide the treatment and care. Care plans must be reviewed regularly to make sure they are effective, and must be revised as needed.
Care Planning Conference
The care plan is developed by an interdisciplinary team—nurse, nurse aide, activities and dietary staff, and social worker, with critical input from the resident and/or family members. All participants discuss the resident’s care at a Care Plan Conference to make certain that all medical and non-medical issues, including meals, activities, therapies, personal schedule, medical and nursing care, and emotional needs are addressed. Resident and family member concerns should be listened to by staff and addressed in the care plan.
Effective Care Plans must be :
- Individualized for each resident;
- Followed by staff closely;
- Written so that everyone can understand it and know what to do;
- Provide assignments to specific staff members;
- Re-evaluated and revised routinely.
Resident and Family Participation in Care Planning
Residents and family members have the right to be involved in the care plan conference in order to make choices about care, services, daily schedule, and life in the nursing home.
Nursing Home Neglect - Liability for Failing to Assess and Plan Care
A nursing home may be found liable for failing to assess a resident and prepare an individualized care plan with measurable goals and time frames. Claims against nursing homes and assisted living residence hold wrongdoers accountable, recover money damages for injured persons and their families, help families to gain emotional closure and make our community safer by protecting others from similar harm.