Page 78 - Ombudsman Participant Manual Optimized_Neat

Assessment and Care Planning
The Resident Assessment and Care Plan Process: Developing an Individualized Care Plan:
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In order know what care and services provide The Care Plan, by law, is initially prepared with
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and how provide them, the law requires careful participation to the extent practicable of the resident

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and thorough assessment of your mom. Staff needs to The

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learn your mom’s strengths and needs. A list as- or the resident’s family or legal representative.
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sessment items relating to your mom includes: initial care plan must be complete by the 21 day of
her stay, and subsequent care plan reviews are re-
• Her life history, daily routines, strengths, in- peated quarterly, or whenever there is a major

terests, food likes and dislikes, and other per- change in a resident’s condition. The initial care plan

sonal information. process begins during the assessment. It is called an

(Think of this information as the important Individualized Care Plan because each resident’s

details about your mother that reflects who

an individual, and which will form
she is as conditions, abilities, needs, routines, and goals are
the basis for planning her care.) unique, requiring a plan of care (road map for care)

• Her ability to function including walking, that reflects who this individual is. The overarching

dressing, using the toilet, and eating. (The goal is for your mother to return home and live as

stroke has affected your mom’s right and independently as possible. There are many little

dominant side, so she will need assistance to
regain independence.) goals along the way. Care plan goals are all meas-

mental conditions
• Physical or that may affect urable, time limited, and the team member responsi-

her ability to recover. (Except for the stroke, ble for each is identified. This simply means that

she is quite healthy mentally and physically.) each goal will be clearly identified and stated. Each

• Her potential for improvement. (Her physician goal will also list an estimated time for accomplish-
expects her to recover and go home.)

• Communication abilities. (Her speech is ment, as well as the specific team member(s) respon-

slowed.) sible in assisting to achieve that goal.

• Nutritional status and medications. (She must

feed herself and manage her own

relearn to Physical Therapy will help your mother to regain the

walk.

medications.) ability to Occupational Therapy will assist her

The assessment is completed by day 7 in a skilled in attaining independence in dressing, eating, and

improve her

unit (your mother’s situation at first); by the 14th day toileting. Speech Therapy will help to

in a nursing facility (long term chronic care); and slow speech pattern. But therapy only takes up a

once a con- few hours each day. The IDT must plan what hap-

year thereafter, or whenever a resident’s

dition changes. The assessment is done by the inter- pens for the rest of the 24-hour period. This plan

disciplinary team (IDT) that includes: the resident, must support your mother’s goal for independence

direct caregiver(s), nurse, physician, physical thera- and prevent any harm from occurring. The Plan of

pist, occupational therapist, speech therapist, activity Care must then be relayed to each staff member, in-

therapist, dietitian, and social worker. The assess- cluding the Certified Nursing Assistants (CNAs), so

ment information is the foundation for the care plan- that everyone is consistent in helping your mom

ning process. reach her stated goals.

Traditionally, nursing homes have used nursing/medical model care plans. That type of plan is not suited to individual-

ized nursing home care. written from the staff perspective rather than each resident’s perspective. Here is an exam-

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ple of what you may find:
Problem Goal Approaches
Incontinence Will become Assist to Bedpan at 6 am, 9am, 12 noon, 4pm, 9pm (or when requests) (CNA) Assess

independent ability to stand and pivot on left leg in one week to transfer to commode or toilet, 2/14/05
in toileting (N/PT*).
Office of the LTC Ombudsman
Office of the LTC Ombudsman
Version 1.0 September 2020
Version 1.0 September 2020
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