ASSESSMENT AND CARE PLANNING: THE KEY TO GOOD CARE A Guide for Nursing Home Residents and Their Families © 2000 Nursing Home Ombudsman Agency of the Bluegrass, Inc. Why Do You Need to Know About Assessment and Care Planning? Every person in a nursing home has a right to good care, under the law. The law says the home must help the people "attain or maintain" their highest level of well-being-- physically, mentally and emotionally. To give good care staff must access each resident and plan care to support each person's life-long patterns, and current interests, strengths and needs. Resident and family involvement in care planning gives staff information they need to make sure residents get good care. What Is a Resident Assessment? Assessments gather information about how well residents can take care of themselves and when they need help in "functional abilities" -- how well they can walk, talk, eat, dress bathe, see, hear,communicate, understand and remember. Staff also ask about resident's habits, activities and relationships so they can help residents live more comfortably and feel more at home. The assessment helps staff look for what is causing a problem. For instance, poor balance could be caused by medications, sitting too much, weak muscles, poor fitting shoes, a urinary infection or an earache. Staff must know the cause in order to give treatment. What is a Plan of Care? A plan of care is a strategy for how the staff will help a resident. It says what each staff person will do and when it will happen (for instance -- the 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. Care plans can address any medical or non-medical problem (example: incompatibility with a roommate). What Is a Care Planning Conference? A care plan conference is a meeting where staff and residents/families talk about life in the facility - meals, activities, therapies, personal schedule, medical and nursing care, and emotional needs. Residents/families can bring up problems, ask questions, or offer information to help staff provide care. All staff who work with a resident should be involved - nursing assistants, nurse, physician, social worker, activities staff, dietician, occupational an physical therapists. When Are Care Planning Conferences Held? Care planning meetings must occur every three months and whenever there is a big change in a resident's physical or mental health that might require a change in care. The care plan must be done within seven days after an assessment. Assessments must be done within fourteen days of admission and at least once a year, with reviews every three months and when a resident's condition changes. What Should You Talk About at the Meeting? Talk about what you need, how you feel; ask questions about care and daily routine, about food, activities, interests, staff, personal care, medications, how well you get around. Staff must talk to you about treatment decisions, such as medications and restraints, and can only do what you agree to. You may have to be persistent about your concerns and choices. For help with problems, contact your local ombudsman. How Residents and Their Families Can Participate in Care Planning Residents have the right to make choices about care, services, daily schedule and life in the facility, and to be involved in the care planning meeting. Participating is the only way to be heard. Before the meeting:
During the meeting:
After the meeting:
Families:
A Good Care Plan Should:
Prepared by the National Citizens Coalition for Nursing Home Reform (NCCNHR), 1224 M Street, N.W., Suite 301, Washington, D.C., 20005-5183 |
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