Nursing home care plans- 10 things you didn’t know

Episode 163
Categories: Regulations

Care plans are required for every nursing home resident. Care plans are the blueprint for care and treatment. But what else? In this week’s episode, we shine the light on ten things you might not know about nursing home care plans.

Nursing home care plans are required by Federal and State law

So here we go. All right, starting at number 10, nursing home care plans are required by federal and state law. So a care plan is not developed out of the goodness of the heart of the nursing home. It’s not left up strictly to the policies and procedures of the nursing home. Care plans are required under federal and state law. So on a federal level, the United States Congress in 1987 passed OBRA, which is the Omnibus Reconciliation Act of 1987, the Nursing Home Reform Act, which provides the guidelines for the operations of nursing homes all across the country, everything from staffing levels to what a nurse aide is and what they can do to how assessments are conducted to diet and exercise for residents. Everything on how to run a nursing home is in those federal regulations in OBRA.

And a part of those federal regulations is when, how to conduct a care plan or to effectuate a care plan in a nursing home. So again, it’s not because the nursing home just wants to be your best friend or because they think it’s clinically necessary. It is in fact necessary under federal and state regulations.

Now the Georgia regulations are not quite as extensive as the federal regulations on care plans, but there are some Georgia regulations that apply with regard to when and how a nursing home should conduct or effectuate a care plan. So number 10, nursing care plans are in fact required by federal and state law.

A baseline care plan is required within 48 hours of admission to the nursing home

Number nine, a baseline care plan is required within 48 hours of admission to the nursing home. So when we say care plan, typically what we mean is what’s called a comprehensive care plan. And we’ll get to that in a second but a comprehensive care plan is going to cover every component of that nursing home’s – I’m sorry, of that resident’s life, everything from activities of daily living to behavior patterns, all those kinds of things, all those interventions of care moving forward. But the nursing home upon admission has 48 hours to at least get a quick care plan in place so that the resident doesn’t hurt him or herself or isn’t injured because of improper care, so the nursing home under federal regulations needs to, as soon as that resident is admitted within two days have at least a working understanding, a working blueprint for how they’re going to care for that resident before a comprehensive care plan is put in place.

So there’s a baseline care plan and there’s a comprehensive care plan. It’s not to say they can’t do comprehensive care plan on day one, but typically that’s not what happens. They’re going to put a baseline care plan in place. It’s kind of like a stopper until a comprehensive one can be done.

A comprehensive care plan is required after all comprehensive assessments

Number eight, a comprehensive care plan is required after comprehensive assessment. So as we mentioned several times in multiple episodes, every resident is required to have a comprehensive assessment done, head-to-toe assessment of everything from cognitive capacity to skin integrity to behavioral patterns to what diet they’re going to need to what medications they need. And baseline assessment, that’s when they comprehensive care plan comes into play. So based on the risk factors for skin integrity, for example, the interventions in the care plan might be turn and reposition every two hours, certain medications, certain diets, that type of thing.

So there’s the baseline care plan that we talked about and there’s the comprehensive care plan that is really the blueprint, the way forward in terms of care and intervention for that resident, and that is typically required within seven days of a comprehensive assessment being done. So it’s not up to the whim of the nursing home. There is a deadline and it’s within seven days of a comprehensive assessment. So you’ve got the baseline care plan that’s within 48 hours. Then you’ve got to do the comprehensive assessment within 14 days, and then within seven days of that comprehensive assessment, you have to have a comprehensive care plan do. So that’s your number eight.

Nursing home care plans must be developed by an interdisciplinary team

Number seven, care plans must be developed by an interdisciplinary team. So what is an interdisciplinary team? I can’t even say it. Again, the main objective of this care plan is to get a person-centered approach to the care and treatment of that resident, and you typically can’t get that if you’re dealing with one nurse that maybe only works first shift because there might be issues that would affect a resident’s treatment that occurs during third shift. So the idea of the interdisciplinary team is to get more than one person over the course of shifts at that nursing home to help develop the care plan.

Under federal regulations, at minimum, the interdisciplinary care team is required to have at least one physician, the attending physician, one nurse that is in charge of direct care of the resident, at least one nurse aide that provides direct care to the resident, nutrition staff and theoretically you want to get the family involved. But that is typically what an average interdisciplinary team is – physician, RN, aides, nutrition staff, dietitian who are actively participating in the direct care of that resident. So not just one nurse aide jotting things down on a chart for the care plan. It is a deliberative body looking out for that specific resident based on that resident’s comprehensive assessment.

Care plans must document objectives

All right, number six, care plans must document objectives. So it’s not enough that the care plan says, “We need to turn or reposition Ms. Smith every four hours,” or “Ms. Smith needs to have a soft diet,” or that “Ms. Smith needs to have a catheter changed once a month” – interventions in other words. It’s not enough to have the interventions. It’s not enough to have the care outline on the care plan.

The interventions must be implemented based on some type of objective. So for example, the resident that needs to be turned or repositioned, that’s for the objective of preventing pressure ulcers. So the objective of that care plan might say, “We are going to keep Ms. Smith free from pressure ulcers for the next nine weeks and then we revise,” or “Ms. Johnson will require a soft diet until such time that she goes to the dentist and can chew her food.” There is going to be some type of goal that we’re trying to achieve even if it’s just to maintain the resident’s baseline. There needs to be some type of reason why we’re doing this and some direction that we’re headed. The care plan has to be that level of holistic look at the life of that resident. What we’re doing, why and where we’re headed.

Care plans must include specific interventions to achieve objectives

Number five, care plans must include specific interventions to achieve those objectives. So a lot of times we see care plans because it will just say something along the lines of, “Keep resident happy. Provide resident with stimulation.” That is not enough. There needs to be specific interventions. So for example, “Encourage resident to participate in Thursday bingo. Take resident to cafeteria for group dining so that resident does not dine alone in the resident’s room.” Some type of specific action that should be taken, not generalized action but specific action that should be taken to achieve the objectives that are outlined in the care plan. It’s not enough to be some type of generalized cookie-cutter statement.

Nursing home care plans must be periodically reviewed and revised when appropriate

Number four, care plans must be reviewed and revised when appropriate. So again, federal regulations require that the nursing home assess the resident, develop the care plan and then revise the care plan, because things change. Even if you’re doing everything correctly on the care plan, the resident can have a negative outcome. And if you continue with that care plan despite the negative outcome, the resident will get worse.

So it’s not enough to assess and do the care plan, but you have to make sure the care plan is actually working. And when it’s not working, you have to do a reassessment and redo the care plan and change objectives based on eliminating the negative outcomes. And unfortunately, this is where a lot of nursing homes fail because they think it’s enough to do the care plan and effectuate the care plan. Sometimes a bedsore develops because the nursing home, even though the nursing home has assessed the resident correctly and has effectuated the care plan correctly, but maybe they need to do something else. Maybe instead of turning every two hours, you need to turn every 30 minutes, alternatives to interventions that aren’t working, these types of things. So revising the care plan where appropriate is required under federal law.

The resident and the resident’s family should be a part of the care plan process

All right, number three, the resident and the resident’s family should be a part of the care plan process. Now this is actually one of the first questions I ask prospective clients when they call me is they say, “I had no idea that my loved one was on a different type of medication,” or “I had no idea that my loved one was not eating or losing weight.” And I say, “Were you in the past however many months involved in the care plan meeting?” and they’ll say, “No.” And I’ll say, “Okay, was that ever part of the process?” And they might say, “No,” and that’s a problem, because as I mentioned before the planning process benefits from more people – the more the merrier. And the more you can get the family involved, because theoretically the family knows this resident very well, their behavior patterns, triggers for behaviors, these types of things, getting the family involved in the care planning process can be extremely beneficial for the resident.

So when the family is not involved, this can increase the likelihood of negative outcomes. This can increase the likelihood of injuries because technically you really don’t have a good assessment, you don’t have a good blueprint in the care plan because you’re missing key information from the family. So federal regulations recommend and Georgia regulations recommend the family be involved in the care planning process.

The care plan must attempt to achieve resident’s highest practicable physical, mental, and psychosocial well-being

Number two, the care plan must attempt to achieve residents’ highest practice physical, mental and psychosocial wellbeing. This means that if the resident has a certain level of mobility, they maintain that mobility and don’t decrease, that if the resident is able to brush their own teeth and groom themselves, that they continue to be able to brush their teeth and groom themselves.

Only when it’s clinically not possible based on medical conditions should a resident’s life, quality of life, deteriorate. So the care plan needs to reflect these things. If the resident can brush their own teeth, then the care plan should lay that out and have the objective of the resident will be able to continue performing these particular activities of daily living, because often what we see with nursing homes is they’ll say, “These people are old, sick and dying. These people are already on their way out.” And that’s not the case. The idea is that the nursing home facilitates the ability for these people to live their best life. If their best life is not having bedsores, then that’s what it is, and just because they’re in there doesn’t mean they deserve to get bedsores. If living your best life is not getting a UTI, then that’s what it is.

So no one needs to be cured of chronic illnesses. No one needs to miraculously be able to walk when they haven’t been able to walk in 10 years. The only thing the federal regulations require is they do the best they can, they take reasonable steps to maintain the highest practical ability of these residents, both mental, social, emotional and physical.

Nursing Home care plans must be person-centered and not cookie-cutter

And number one “Ten Things You Might Not Have Known About Care Plans In Nursing Homes” is that care plans must be person-centered and not cookie-cutter. So person-centered means that individuals conducting assessments, people putting together these care plans, actually lay eyes on someone, that it’s not just done based on medical records. It’s not just, “Okay, everybody that comes in here, these are what we’re going to do.” That is illegal. That is improper under the law.

Every resident needs to be assessed for their particular specific needs. That’s not to say that there are not general, like a paradigm, an index, a guideline for how we approach, but taking the variables from the person and computing them out, okay fine. But you can’t just come and, “Okay, this care plan is for you. You get a care plan. You get a care plan. You get a care plan.” No. The resident comes to the facility, the facility does what it can to understand what that individual’s needs are, their preferences, their likes and their medical needs. And that’s when they compute a care plan. It’s not like – I guess that’s what differentiated McDonald’s from Burger King back in the day is that you walked into McDonald’s, your burger’s already there. That’s not correct under the law. It’s more like Burger King. You go in and only then once you’ve entered do you get to have it your way. I guess maybe I know too much about fast food culture, but that’s the number one thing you didn’t know about care plans, that theoretically your loved one’s nursing home care plan does not look the same as his or her roommate’s, and that is by design so no one falls through the cracks.

Nursing home care plans can make or break a residency. I hope that you’ve found this episode informative. If you did, please let us know. Like an subscribe. If you watched this on YouTube, please leave a comment, let us know how we’re doing. Every other week you can get a new episode of the Nursing Home Abuse Podcast. Monday morning is when they drop and I believe I think that covers it and that’s all I have to say about that. So with that, we’ll see you next time.