A Nursing Home Care Plan

Published on May 13, 2015

Once your loved one enters a nursing home, the nursing home is required to create a care plan. This helps the nursing home understand a resident’s medical, nursing, and psychological needs and create a plan based on those needs. More importantly, this is your opportunity to be detailed in relaying your loved one’s needs and hold the staff legally responsible. We will expand on this, but first, let’s define what exactly a care plan entails.

A basic care plan includes: (1) a health assessment (a review of your loved one’s health condition) that begins the day you’re admitted and must be completed within 14 days of admission, (2) a health assessment at least every 90 days after your first review and possibly more often if a medical status changes, and (3) ongoing, regular assessments of your condition to see if the resident’s health status has changed, with adjustments to the care plan as needed.

According to Medicare.gov, your care plan may include the following depending on your needs:

-What kind of personal or health care services your loved one requires
-What type of staff should provide those services
-How often those services are needed
-What kind of equipment or supplies are needed (this can be anything from a wheelchair to a feeding tube)
-What are the diet requirements (if applicable) and food preferences
-Health or personal goals
-How the care plan will help your loved one achieve those goals
-Details on whether your loved one plans on returning to the community, and if so, a plan to reach this goal

In creating a care plan, you’ll want to play an active role in ensuring detailed information is in your loved one’s plan. For instance, if your loved one has dementia and needs 1-on-1 supervision during mealtimes, baths, etc… you’ll want to ensure this language is in the care plan. Avoid language such as “constant supervision.” Although you would think this means to have one person watching your loved one at all times, it legally only means that there has to be a caregiver in the facility to eyeball your loved one every so often. By using the words “one on one” and specifying when this is needed (during bath time, meals, etc…), you can hold the facility legally responsible to do this.

Another common problem we see is when specifying needs during meal times. Many residents have special eating requirements. For example, if your loved one is at risk of choking, you’ll want to ensure his or her food is cut up into small pieces, but you’ll want to specify how small. Specific language like “cut up all food into dime-sized pieces” or “kidney bean sized pieces” is ideal. Again, you want to use language that leaves nothing to the imagination. Avoid simply saying, “cut food into bite-sized pieces or small pieces.” In addition, you could add that your loved one must take a drink of water between every bite or that your loved one must feed themselves with a spoon to slow down their speed of eating. You know your loved one better than anyone. Don’t be afraid to share the tricks you’ve learned to ensure a healthy and safe experience for your loved one.

Although nursing homes are required to abide by the care plan, the Department of Health and Human Services found that nursing homes often fail to meet care plan requirements. In fact, when studying a simple random sample of Skilled Nursing Facility stays from 2009, they found that in 37 percent of stays, the facilities did not develop care plans that met requirements or did not provide services in accordance with care plans.

Unfortunately, you can’t be at the nursing home with your loved one 24/7. However, by taking an active role in your loved one’s care plan and visiting often, you can check with the nursing staff to ensure proper steps are being taken. Sometimes the old adage proves true: the squeaky wheel gets the grease.