Assessment and Care Planning

Each and every person in a nursing home has a right to good care under the 1987 Federal Nursing Home Reform Law. The law, which is part of the Social Security Act, says that a nursing home must help each resident "attain or maintain" his or her highest level of well being - physically, mentally, and emotionally. To give good care, staff must assess and plan care to support each resident’s life-long patterns, current interests, strengths, and needs. Care planning conferences are a valuable forum for residents and families to voice concerns, ask questions, give suggestions, learn nursing home strategies, and give staff information (such as resident background and daily routine). This requirement in the law is vital to making sure residents get good care.

Resident Assessment

Assessments gather information about the health and physical condition of a resident and how well a resident can take care of themselves. This includes assessing when help may be needed in activities of daily living (ADLs) or "functional abilities" such as walking, eating, dressing, bathing, seeing, hearing, commun- icating, understanding, and remembering. Assessments also should examine a residents’ habits, activities, and relationships in order to help him or her live more comfortably and feel at home in the facility.

The assessment helps staff to be aware of strengths of the resident and also determine the reason for difficulties a resident is having. An example of where a good assessment helps: A resident begins to have poor balance. This could be the result of medications, sitting too much, weak muscles, poorly fitting shoes, or a urinary or ear infection. Staff must find out the cause of a problem in order to give good treatment. Figuring out the cause is much easier with a good assessment.

Assessments must be done within 14 days of the resident’s admission to a nursing home (or 7 days for Medicare residents) and at least once a year after that. Reviews are held every three months and when a resident’s condition changes.

After the assessment is completed, the information is analyzed and a care plan is developed to address all the needs and concerns of the resident. The initial care plan must be completed within seven days after the assessment. The care plan is a strategy for how the staff will help a resident every day. This care plan says what each staff person will do and when it will happen (for example, a nursing assistant will help Mrs. Jones walk to each meal to build her strength). Care plans must be reviewed regularly to make sure they work and must be revised as needed. For care plans to work, residents must feel they meet their needs and must be comfortable with them.

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 agreed upon and addressed. Resident and family member concerns should be listened to by staff and addressed in the care plan. A good Care Plan Conference takes time. It should not be rushed, and could take at least one hour. Every 90 days after development of the initial plan, or whenever there is a big change in a resident’s physical or mental health, a Care Plan Conference is held to determine how things are going and if changes need to be made.

Good Care Plans Should

•  Be specific to that resident;
  
  
• Be followed as an important guideline for providing good care for the resident;
  
  
• Be written so that everyone can understand it and know what to do;
  
  
• Reflect the resident’s concerns and support his or her well-being;
  
  
• Use a team approach involving a wide variety of staff and outside referrals as needed;
  
  
• Assign tasks to specific staff members;
  
  
• Be re-evaluated and revised routinely.

Steps for Residents 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. Even if a resident has dementia, involve them in care planning as much as possible. Be aware that they may understand and communicate at some level and help the staff to find ways to communicate and work with them. They can express when they hurt or suffer if they are actively listened to. Participating in care plan conferences is a way to be heard, raise questions, and come to a clear agreement with the facility about how the resident will be cared for.

Before the meeting:

•  Ask staff to hold the meeting at a convenient time for you and/or your family member;
  
  
• Ask for a copy of the current care plan (if one already exists) so that you can examine each aspect thoughtfully;
  
  
• Know about or ask the doctor or staff about your or your loved one’s condition, care, and treatment;
  
  
• Plan your list of questions, needs, problems, and goals, and;
  
  
• Think of examples and reasons to support changes you recommend in the care plan.

During the meeting:

•  Make sure the resident is involved and listened to carefully.
  
  
• Discuss options for treatment and for meeting your needs and preferences;
  
  
• Ask questions if you need terms or procedures explained to you;
  
  
• Be sure you understand and agree with the care plan and feel it meets your needs;
  
  
• Ask for a copy of the care plan;
  
  
• Find out who to talk to if changes in the care plan are needed, and;
  
  
• Find out who to talk to if there are problems with the care being provided.

After the meeting:

•  Monitor whether the care plan is being followed;
  
  
• Inform the resident’s doctor about the care plan if s/he was not directly involved;
  
  
• Talk with nurse aides, staff or the doctor about the care plan, and;
  
  
• Request another meeting if the plan is not being followed.

See NCCNHR’s "Resolving Problems in Nursing Homes" for additional information.