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Resident Assessments and Care Plans
The rise in abuse and neglect at nursing homes has prompted federal and state legislatures to create rules and regulations to curb abuse. Nursing homes that receive federal funding must comply with federal legislation calling for a specific standard of care. A nursing home must "care for its residents in such a manner and in such an environment as will promote the maintenance or enhancement of the quality of life of each resident." See U.S.C. 42 § 1395i-3. Among the specified rules, nursing homes must conduct a comprehensive, accurate, standardized, and reproducible assessment of each resident's functional capacity. 42 C.F.R. § 483.20. From this assessment, the nursing home should develop a comprehensive care plan for each resident.
Resident Assessments
To give a resident the best possible care, federal regulations call for an initial comprehensive assessment. The assessment should gather important information about the resident to enable the facility staff to develop an individualized care plan. The comprehensive assessment must be completed within 14 calendar days of the resident's admission, following a significant change in a resident's physical or mental condition, or no less often than once every 12 months. The assessment should be conducted by a registered nurse. 42 C.F.R. § 483.20.
Health and Functional Abilities
The assessment should gather information about the resident's health and functional abilities. This includes information about eating, dressing, walking, bathing, sight, hearing, communicating, and cognitive abilities. Any difficulties or particularities should be noted.
Social Concerns
In addition, the initial assessment should gather information about routines, habits, moods, hobbies, activities, and relationships. An assessment should inform care providers what makes a good day for a particular resident. The gathering of such social information is intended to make a resident's stay as comfortable, fulfilling, and dignified as possible.
The Care Plan
The assessment should be used to formulate, revise, and review a detailed plan of care. The original plan of care should be completed within 7 days after the completion of the assessment. A comprehensive care plan should include measurable objectives and timetables to meet a resident's medical, nursing, mental, and psychosocial needs as identified in the resident's assessment. 42 C.F.R. § 483.20(d)(1). An effective care plan should address all aspects of life in a nursing home. It should state what each staff person will do for the resident, and when it should be done. The plan must be reviewed regularly to assure that all planned treatments and recorded information are accurate and up to date. The plan should be revised as needed on a continual basis.
Collaboration
A care plan should be the product of a scheduled care plan conference. A care plan should be developed through the collaboration of nurses, physicians, dieticians, therapists, and importantly, the resident and the resident's family. All parties involved should feel comfortable in contributing ideas and concerns.
Summary
An effective care plan must:
- Be specific to an individual resident
- Reflect the concerns and desires of the resident
- Reflect the concerns and desires of the team involved in the making of the plan, including the concerns of the resident and the resident's family and friends
- Be easy to understand
- Include specific goals, timetables, and name those staff members who will help in each treatment and activity
- Be followed as the primary guide for treatment and everyday life in the facility
- Updated and revised as needed on a continual basis
Conclusion
Resident assessments and care plans are essential to assuring the comfort, treatment, and dignity of residents in nursing homes. In addition, they provide a concrete record of each resident's day-to-day activities. It is important that all concerned with a resident's well being take an active role in the development and revision of care plans. Do not be afraid to ask questions and voice concerns at any stage in a resident's stay. In the end, residents, the resident's family and even friends have important rights with regard to the living arrangements and treatment of a loved one in a nursing home. If you have concerns regarding the assessment or care plan for a nursing home resident, an experienced elder law lawyer can provide you with valuable information and legal advice.
Form: Assessments and Care Plans
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