What is a nursing home care plan?

What a care plan contains

A care plan is organized by problem. For each one you should see:

• The problem or risk, for example "at risk for falls due to weakness and dementia" or "at risk for pressure injury."
• A measurable goal, such as "will have no falls with injury this quarter" or "skin will remain intact."
• Interventions: the specific things staff must do. Good interventions are concrete: "turn and reposition at least every two hours," "bed in lowest position with floor mats," "offer fluids every shift," "two-person assist for transfers."
• Who is responsible (nursing, the nursing assistants, dietary, therapy, social work) and when the plan will be reviewed.

When it is written and updated

• Within 48 hours of admission, a baseline care plan covering immediate needs such as medications, diet and safety.
• Within 7 days after the first comprehensive assessment (the MDS, which is due within 14 days of admission), the full care plan.
• After every later assessment, usually about every three months, and whenever the resident's condition changes significantly, such as after a fall, a hospital stay, a new wound or a big weight loss.

Your right to take part

Residents have the right to take part in planning their care, to choose who else attends, to see the care plan, and to have meetings scheduled when they and their family can attend. If the resident cannot participate, the health care agent, guardian or other representative steps in. See how to prepare for a care plan meeting.

How to tell whether the plan is being followed

A care plan only matters if staff carry it out. Compare what the plan says with what you see. If the plan calls for a pressure-relieving mattress, heel protectors, a bed alarm or two-person transfers, look for them. If the plan says "encourage fluids" but the water pitcher is always full and out of reach, raise it.

The records show whether interventions were documented: the nursing assistant flow sheets, the medication and treatment records, and the nursing notes. Gaps between the plan and those records are often the first sign of neglect.

Red flags

• The same generic plan for every problem ("monitor," "encourage," "as needed") with no specific steps.
• The plan was not updated after a fall, a new wound, a hospital stay or major weight loss.
• No one has invited you to a care plan meeting in months.
• Staff on the floor do not know what the plan says.