Page 74 - Ombudsman Participant Manual Optimized_Neat

What does a Care Plan look like?

SAMPLE CARE PLAN

D ate/ Problem Goal Interventions Responsible Modality Review Date

9/1/14: 1. Resident will 1. Physical Therapy 5 days per 1. PT 12/1/14

Fractured Left ambulate 5 feet week; 2 hours per day.
2

Hip using rollator 2. Pain Management as per 2. Nursing
walker with physician orders

minimal pain 3. Range f motion exercises 3. Restorative Nursing
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daily

4. Nursing staff will ambulate 4. Nursing

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resident o bathroom- assist of

two with rollator walker 5. Nursing; social services to

5. Return visit/exam to assist with transportation if

orthopedic surgeon as per needed

schedule

9/1/14: 1. Resident will 1. Obtain up-to-date dietary 1. Dietary 12/1/14

Decreased maintain current preferences from resident

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appetite weight through 2. Resident will dine in dining 2. Nursing o assist with

next review room for all meals except ambulation (as tolerated); will

breakfast transport via wheelchair if

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2. Resident will 3. Snacks n afternoon and resident reports pain or
a
eat least 80% evening fatigue

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of each meal

3. Nursing

Who decides what the problems, goals, and interventions are?

• The first step in the Care Plan process is a multi-disciplinary assessment known as the MDS (Minimum Data Set). Each

modality/department s assigned sections of the assessment. They are to meet with the resident; review records; and

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then complete the computer-based assessment. NOTE that the resident is to be involved in the assessment process.

SO, for instance, before the social worker completes his/her portion the MDS, they should have met with the resident
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f

and interviewed them on the things they will be “assessing” (discharge plan, mood, etc.) Activities should be asking

about interests, hobbies, etc.

• Next, the assessment generates a list of “triggers” or areas that require consideration/monitoring/response and that

list s the beginning of the Care Plan – each “trigger” must be “Care Planned”.

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• In most nursing homes, there is an RNAC (Registered Nurse Assessment Coordinator) who is responsible for tracking

assessment/Care Plan due dates; triggers, etc. Usually, the RNAC monitors to make sure that each discipline contributes

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goals and interventions to the Care Plan. The RNAC also establishes a weekly Care Plan schedule and they- social
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–

services should be inviting the resident to the actual Care Plan meeting. Inviting the resident to the Care Plan meeting

is REQUIRED by the regulations.

• Even though the Care Plan is “written” the time the meeting is the resident can and should review

already
b
y
convened,

the goals and proposed interventions. Residents can request that the Care Plan be amended to better reflect their

goals and/or preferred interventions, schedule, etc.

y
s

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• The Care Plan meeting usually attended several disciplines: Nursing, therapy, activities, dieta ry, social services, etc.
b

Residents can attend alone; with a family member of their choosing; with an ombudsman; or they could decline to

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attend. l attending a Care Plan meeting will be asked to sign the Care Plan to signal their involvement in the process.

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• Care Plans become part of the resident’s clinical record and can be reviewed at any time by the resident. Care Plan

A

meeting s not required for the resident to simply read over his/her Care Plan.

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the
LTC
of
Office of the LTC Ombudsman
Office
Ombudsman
September
1.0
Version 1.0 September 2020 2020
Version
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