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What is a Patient’s Care Plan in a Nursing Home?

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Nursing homes in Arizona and across the US exist to provide professional, multidisciplinary care for their residents. As part of this commitment, when a resident moves into a care facility, a comprehensive plan is developed within the first two weeks called a care plan.

Though not a legal document, the care plan acts as a blueprint to ensure that standards of health and well-being are met. This article explains the purpose and content of a care plan, and why it’s such a critical document to understand and track.

The injury attorneys at Phoenix Accident and Injury Law Firm near you have significant experience in helping clients who have been a nursing home abuse victim.  Our offices are conveniently located in nearby Chandler, Peoria, and North Phoenix, and we can meet in-person at our nearby offices, over the phone, or video call.  You can contact us for a free consultation, or read on to find out more. 

By the way, we will also help with other problems that have cost you sleep, like finding a nearby doctor who can help you or recommending you to temporary or long-term care options. You and your family’s’ safety and health are our top concern, and even the best legal team isn’t good enough if your quality of life isn’t sustainable while justice and compensation are on the way. The whole point of legal action is to regain quality of life, so we help you long-term as attorneys and short-term as your go-to people. Our familiarity with the local Phoenix courts makes us confident that we can help you get the best settlement possible.

To figure out how the nursing home you have chosen for your family is rated and to see if the home has any prior violations, check out our nursing home index. We’ve compiled all of the nursing homes in Arizona as well as their health code reports.

Additionally, take a look at our Nursing Home Glossary– an index of important words you need to know in a nursing home abuse case and their definitions.

If you are unsure whether or not you can afford an attorney, don’t worry. We only get paid when you settle. Check out our Attorney Fees Calculator to find out more.

To learn more about how a care plan can affect a nursing home abuse or neglect legal claim, read: How does my loved one’s care plan affect an Arizona nursing home abuse claim I plan to file?

What is the purpose of a nursing home care plan?

In every nursing home facility across the US, a comprehensive care plan is developed for each patient which serves as a guide for a specified care team.

If you have cared for a loved one at home, you’ve already experienced a less formal version of a care plan: perhaps you have friends and family taking turns with feeding, bathing, and so on.

The core purpose of a care plan is to:

  • Identify and mitigate risks
  • Prevent health declines
  • Support a resident’s emotional and social needs
  • Benefit their overall wellbeing

A care plan is also crucial documentation that can be used to demonstrate whether or not a given nursing home is following federal laws and standards.

What should a care plan include?

A care plan should detail information about the patient’s health and wellness, as well as directives for support on all levels, including:

  • Managing existing physical conditions (eg: diabetes or allergies)
  • Managing existing psychological conditions
  • Medication protocols
  • Meal time routines
  • Reducing specific risks (eg: falls or choking)
  • Patient preferences and personal needs
  • Social activities to support their well being
  • How often the plan is to be updated
  • Prognosis and health goals
  • Long term and acute health concerns
  • Equipment, supplies (eg: walker, wheelchair, feeding tube)
  • Daily care routines regarding feeding, walking, toilet, etc.
  • How to notify team members of care plan changes
  • Emergency care procedures
  • Relevant services, resources and contacts

A formal and comprehensive health assessment should take place at the time the resident enters the care home, with the care plan developed in the following two weeks.

Having a well-developed care plan for your loved one is crucial. Not only does it ensure specific health directives, it also acts as the key communication tool to coordinate care team members.

Care Plan Meetings

Care plan meetings are the basis for care plan development, and should include all health care providers and relevant family members.

At the outset of the stay, a care plan meeting will set the stage for expectations as well as be a place to voice specific preferences and concerns.

Residents are well within their rights to participate in this meeting, and should have a trusted friend or family member with them.

The meeting should have a representative from each type of relevant care group, for instance:

  • Social and recreational activities
  • Dietitian
  • Physical therapist
  • Primary physician
  • Nurse

An elder law professional attorney may also be present at a care plan meeting if possible.

Don’t leave the meeting until you are certain that the plan meets the specific and detailed needs of the resident. Ask for a copy, and stay in touch with the care team leads.

Are care plans a legal requirement?

The Centers for Medicare and Medicaid (CMS) run nursing homes under a set of guidelines outlined in 42 CFR Part 483, and includes the provision that:

“The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care.”

The state Long Term Care Ombudsman and the Arizona Department of Health Services Bureau of Long-Term Care are key points of contact for state-level complaints and investigations if a care home isn’t meeting these requirements.

States are responsible to follow investigation and reporting procedures in a timely fashion in response to complaints. Governments can penalize homes not in compliance with federal law as outlined in the Nursing Home Reform Act (NHRA).

The federal government can also impose penalties on homes not following and Medicare / Medicaid payments. Homes funded by the CMS should only receive funding if they are in compliance.

The state is responsible for inspections and surveys, and being the body that communicates any problems to the CMS; if a home is not up to standards, the nursing home needs to create a plan of correction to ensure they are back on the compliance list.

If not in compliance, a nursing home may be fined, or have their Medicare funding revoked.

Care Plan Development

The care plan should be drafted in the first two weeks of the resident’s stay, and once confirmed, immediately communicated to all parties involved, including nurses, physicians and family members.

This shouldn’t be the end of the process, throughout the resident’s stay the care plan should be regularly reviewed and updated.

Meetings should occur regularly alongside assessments and reviews, usually every 90 days, unless the patient’s condition warrants greater frequency. Specific health objectives should be clear and attainable.

Coordinating a care team is important especially for aides and other staff members who may not have extensive training like doctors.

Staff will obtain health information as a part of developing a care plan and should involve the resident and family in the plan.

The care plan review process

Anyone involved in the long term care of the patients needs to be kept updated on the plan details, and formal changes should include all parties, including the patients themselves.

A resident’s family is crucial in this process, and should keep an eye on whether or not caregivers are following through properly as they check in with their loved one.

A care plan should be reviewed every 90 days (or more frequently if needed). The care team should reassess the health of the resident and how well their activities are contributing to health goals.

Care team leaders should also take careful stock of how well the actual plan has been implemented, whether or not concerns or gaps have been addressed, and establish new health goals within specific time frames.

Reinforcement of positive activities towards regaining well being should also be highlighted during reviews. Some points to address during care plan reviews might include:

  • Staff stability and consistency
  • Care plan adjustments for hospital care
  • Risk mitigation
  • Patient complaints and concerns
  • Patient preferences with regards to overall comfort, especially if bedridden
  • End of life considerations
  • Improving mobility
  • Preventing infections

How lead health care practitioners develop and review care plans, as well as communicate them, is crucial in ensuring that they are followed accurately.

When Care Plans Fail

A recent study by the US Department of Health and Human Services states that 37% of nursing homes neglected to develop or implement adequate care plans, but Medicare still paid over $5 billion dollars to these facilities.

Specifically, lack of care was found in the areas of wound care, medication management, and therapy activities.

Despite laws designed to protect patient’s rights and ensure proper certification of CMS-funded nursing home facilities, there are clearly inadequacies in the system.

This factor can be tied to the alarmingly high number of abuse cases in nursing homes today: according to one source, 1 out of every 5 nursing home patients in emergency rooms arrived there due to injuries caused by abuse or neglect.

There can be many reasons why a care plan is not followed including:

  • Poor communication
  • Lack of funding
  • Negligent management
  • Insufficient training
  • Abuse
  • Neglect

To reduce the chances of your loved one’s care being compromised, it’s worth regularly checking if their nursing home is following their care plan and keeping it updated.

Get help with your nursing home abuse lawsuit

Despite the implementation of care plans, elder neglect and abuse is still far too common, and nursing home staff and management are regularly found liable for providing insufficient care.

The care plan is essential for tracking and monitoring all elements of care and is especially important should there be nursing home abuse claims filed.

Our team of abuse attorneys is dedicated to seeking damages on behalf of those family members who are being abused and help you find better accommodations for them in the nearby area. We’ve worked on a number of nursing home abuse cases previously in your area and take the time to understand the family’s concerns as well as the situation they believe their loved one is in.

At Phoenix Accident and Injury Law Firm near you, we have more than 15 years of experience helping clients obtain compensation for their and their loved one’s personal injuries, including those from nursing home abuse in the Phoenix area. When you’re ready to talk, please contact our office to arrange a free initial consultation by phone or at our Chandler office, conveniently located near you.

If you or a loved one has been the victim of nursing home abuse, contact Phoenix Accident and Injury Law Firm in nearby Chandler, AZ to speak with an experienced personal injury attorney. We provide personal injury legal services to clients in your area including Chandler, Gilbert, Mesa, Scottsdale, Tempe, and Peoria.

Care Plan FAQs

What if I’m not sure a care plan is being followed?

It is always within your right to ask questions on behalf of your loved one. Speak with the resident about their care and staff to stay on top of things and make sure they are getting the best of care.

If you are still concerned about a resident, or you have proof of neglect or abuse, contact the following Arizona offices and consult a qualified attorney.

Are care plans legally binding?

No, but they are relevant to legal cases as they can be used to find gaps in case (abuse or neglect).

How involved should I be in my loved one’s care planning?

If you are the primary contact and guardian for your loved one, you should be as involved in the care planning process as possible.

Nursing staff should always advise you of meetings, and follow up with copies of the revised plans.

How often should a care plan be reviewed and updated?

Reviews should take place every 90 days or more frequently in accordance with the resident’s changing health needs.