Comprehensive Nursing Nursing Home Care Plans
When you walk into a nursing home, you expect to see a warm and welcoming environment filled with care and compassion. But, for too many residents, the reality is a far cry from what they deserve. Neglect and abuse in nursing homes can have devastating consequences which can lead to serious injuries and even death. In fact, according to a recent study by the National Center on Elder Abuse, up to 33.4% of nursing home residents have reported psychological abuse, and 14.1% have reported physical abuse.
The Noll Law Office, located in Springfield, IL, understands the importance of creating a comprehensive care plan in a nursing home setting. The lawyers at the Noll Law Office have seen the devastating consequences of neglect and abuse in nursing homes and are committed to helping residents. If you suspect abuse or neglect occurred in an Illinois nursing home, contact us for a free case review at (217) 414-8889. They can help you investigate the nursing home to determine whether the nursing home violated the Illinois Nursing Home Care Act or laws.
What is a Comprehensive Care Plan?
Nursing home residents are some of society’s most vulnerable, which is why it’s so important for family members to be aware of the comprehensive care plans in place. These plans provide a detailed guide to how nursing homes should best serve their residents and that they receive quality care.
Comprehensive care plans are living documents created for residents of nursing homes that outline the medical, social, and emotional needs of each resident. They include all aspects of a person’s care, from diet and exercise to medications, activities, and even end-of-life directives. The plans are created after the nursing home team has evaluated a patient’s physical and mental health condition, as well as their social preferences. In other words, they’re tailor-made to fit each individual resident’s needs.
Once completed, comprehensive care plans should be reviewed with family members and updated whenever necessary. It is important for family members to understand what is in the plan so that they can help ensure it is being followed by facility staff. Family members should also pay close attention to any changes in a loved one’s behavior or emotional state that may indicate an issue with the care plan or how it’s being implemented.
At its core, a comprehensive care plan provides peace of mind for both residents and their families, knowing that everyone involved in providing quality nursing home services understands exactly what needs to happen on any given day or situation, allowing them to focus solely on providing dignified care and companionship for those who call these facilities home.
Why is a Comprehensive Care Plan Required?
Comprehensive care plans are mandated by both federal and state law in Illinois and serve an important purpose. Having a detailed comprehensive care plan in place helps keep both residents and their families safe while providing peace of mind knowing all involved parties are on the same page about how best to meet each individual’s needs. It also serves as yet another layer of protection against potential abuse or neglect in nursing home facilities, an issue no one wants to face but unfortunately happens more often than we’d like it to.
Laws Governing Care Plans
The creation and implementation of care plans in a nursing home setting are regulated by federal and state laws and entities, including the Centers for Medicare & Medicaid Services (CMS) and the Illinois Department of Public Health (IDPH). These regulators are tasked with monitoring nursing home residents to confirm that they receive the care and services they need and that care plans are based on a comprehensive assessment of each resident’s needs.
The CMS regulations outline specific requirements for care plans, including regular review and updating of care plans. The IDPH also enforces the Residents Bill of Rights, which spells out the rights of nursing home residents and includes rules about how care plans are made and carried out.
According to the regulations, care plans must be reviewed and updated regularly and must include specific information, such as medical history, health status, functional abilities, special needs, medications, treatments, and discharge plans. CMS and IDPH have the authority to impose penalties or take corrective actions if regulations are not met, making it a necessary licensing requirement for nursing homes to adhere to these guidelines.
It is important to note that a comprehensive care plan must be unique to each resident, considering their unique needs and circumstances. It needs to be available to the resident, their family, and the care team, and it needs to be checked often to ensure it is accurate and up-to-date.
What Should a Nursing Home Care Plan Include?
A comprehensive nursing home care plan should include a wide range of information so that residents receive the care and services they need. The plan must be developed within 48 hours of the resident’s admission. The instructions need to provide effective and person-centered care for the resident that meets professional standards of quality care. At a minimum, the care plan should include the following elements:
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Assessment Information
To provide person-centered care, this section should thoroughly evaluate the resident’s needs and health, including their medical history, functional abilities, and special requirements.
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Goals and Objectives
The care plan should outline the goals and objectives for the resident’s health and well-being, taking into account any relevant medical conditions.
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Treatment Plan
The resident’s medications, treatments, and other medical interventions should be detailed in this section.
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Daily Routine
The daily routine for the resident, including activities of daily living such as bathing, dressing, and eating, should be outlined in this section.
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Discharge Plan
This section should outline the resident’s discharge plan, including any follow-up care or services required after leaving the nursing home.
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Collaboration with the Family and Care Team
The involvement of the resident’s family and the care team in creating and implementing the care plan should be described in this section.
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Monitoring and Review
This describes how the care plan will be monitored and reviewed, along with any necessary routine assessments and updates. The care plan should be reviewed at least once every three months and more frequently as needed to ensure accuracy and up-to-date information.
Care plans must be accessible to the resident, their family, and the care team and are reviewed regularly so they remain up-to-date and accurate. A comprehensive care plan should also support the resident’s dignity, compassion, and respect and offer personalized and coordinated care, support, or treatment.
Regular Review and Updating of Care Plans
A comprehensive care plan is not a one-time event but an ongoing process that requires regular review and updating. This is because residents’ needs and health status can change over time, requiring adjustments to their care plans.
A resident’s health and needs can change quickly, and without a regularly updated care plan, they may not receive the care and services they require. Neglect and abuse can occur when the care plan is not updated to reflect changes in the resident’s condition.
Take, for example, one case our firm encountered: A nursing home failed to document a cut on the back of an elderly resident, which led to the development of a stage 4 pressure sore due to lack of rotation. This type of situation highlights how negligence in documenting changes can put vulnerable residents at risk for harm, if this cut had been documented in the patient’s care plan, it could have been addressed earlier and prevented further injury.
Collaboration with Medical Professionals
Creating and implementing a comprehensive care plan in a nursing home setting requires collaboration with a wide range of professionals, including medical professionals. These professionals play a critical role in ensuring that residents receive the appropriate care and services and avoid neglect and abuse.
Medical professionals, such as physicians, nurses, and other healthcare providers, can provide valuable input in creating care plans. They can offer insights into the resident’s medical history, health status, and relevant medical conditions. They can help to make sure that the care plan is individualized to meet the resident’s unique needs and circumstances.
Having medical professionals involved in the care plan process can also help ensure that residents receive the appropriate medications, treatments, and other necessary medical interventions. This can help prevent neglect and abuse and that residents receive the highest quality of care possible.
In addition, collaboration with medical professionals can help make sure that care plans are reviewed and updated regularly, considering any changes in the resident’s health and well-being. This helps residents receive the appropriate care and services they need and that their care plans remain comprehensive, individualized, and up-to-date.
The Role of Family and Caregiver
In the nursing home setting, family and caregivers play a critical role in ensuring that residents receive the care and services they need and in avoiding neglect and abuse. The care plan process should include the involvement of family and caregivers.
Family and caregivers can provide valuable input and support for the resident, including information about their health history, daily routines, and preferences. This information can help ensure that the care plan is tailored to each resident’s specific needs and circumstances.
In addition, involving family and caregivers in the care plan process can also help ensure that the resident receives the appropriate care and services and that their care plan remains up-to-date and accurate. Family and caregivers can also serve as advocates for the resident, ensuring that their rights and needs are respected and met and that the care provided is in compliance with the regulations set forth by the Centers for Medicare & Medicaid Services (CMS) and the Department of Public Health (IDPH) as well as the Illinois Nursing Home Care Act.
The involvement of family and caregivers is beneficial for the resident and the nursing home, as it helps foster a collaborative and supportive environment for all involved.
Care Plan to Help Prevent Falls
Falls are common in nursing homes and can result in serious injury or even death. To help prevent falls, it is important to conduct thorough assessments of each resident’s fall risk and create a care plan to address this risk.
The assessments should include information about the resident’s physical condition, medical history, functional abilities, and any environmental factors contributing to their risk of falling.
Under the regulations set forth by CMS and IDPH, nursing homes must assess each resident’s risk of falling and implement interventions to prevent falls. If the care plan is not followed, or if the resident’s risk of falling is not properly assessed, it can result in serious injury or even death. Nursing homes must take the necessary steps to prevent falls, including conducting thorough assessments and creating comprehensive care plans.
The STEADI Initiative
One example of a successful fall-prevention program is the CDC’s Stopping Elderly Accidents, Deaths, and Injuries (STEADI) initiative. This initiative includes several steps to help prevent falls in nursing homes, including screening for fall risk, assessing for specific risk factors, and providing appropriate interventions. It also includes staff training, integration into the workflow and electronic health record, resident education, and an implementation and monitoring plan.
In a recent case handled by the Noll Law Office, a nursing home failed to follow a create a fall prevention plan. They left a remote which controlled the chair near a resident with dementia who used it. The chair dropped her onto the floor, breaking her ankle. This resulted in her never walking again. In addition, to providing the necessary preventive safeguards for the safety of the resident, this situation could have been prevented if the nursing home created and followed a comprehensive fall prevention plan.
This highlights the importance of proper implementation of fall-prevention programs like STEADI, as failure to do so can result in devastating consequences for residents. Nursing homes must take their responsibility to prevent falls seriously and conduct thorough assessments and implement effective care plans for safety and well-being of their residents.
Care Plan to Help Prevent Bedsores
Bedsores, also known as pressure ulcers, are another frequent occurrence in nursing homes and can cause significant harm or spread a fatal infection. Each resident’s risk of developing bedsores should be thoroughly assessed, and a care plan should be developed to address this risk to help prevent bedsores.
The assessments should include information about the resident’s physical condition, medical history, functional abilities, and any environmental factors that may contribute to their risk of developing bedsores. This information should be used to create individualized care plans to meet the resident’s unique needs and circumstances.
According to the rules established by CMS and IDPH, nursing homes must use appropriate skin care and repositioning techniques to prevent the occurrence of pressure ulcers and routinely assess each resident’s risk of developing bedsores. It can cause serious injury or even death if the care plan is not followed or the resident’s risk of developing bedsores is not correctly assessed. Nursing homes must take the necessary measures to prevent bedsores, including having a special wound doctor or nurse on staff. This specialist can provide additional assessments and recommendations on how to best prevent bedsores in each individual resident.
Nursing Home Abuse Lawyers: Noll Law Office
A comprehensive care plan is essential to ensure that nursing home residents receive the appropriate care and services they need. The care plan should be based on a thorough assessment of the resident’s needs and health status. It should be developed in collaboration with the resident, their family, and the interdisciplinary care team.
The care plan should include information about the resident’s personal details, medical history, health status, functional abilities, special needs, medications, treatments, and discharge plan. It should also address the resident’s risk of falls and bedsores and include interventions to prevent these potential issues. The care plan should be reviewed regularly so that it remains up-to-date and accurate and should be accessible to the resident, their family, and the care team.
The Noll Law Office is committed to ensuring that residents receive the appropriate care and services they need and will work with you to ensure that your loved one’s care plan is comprehensive, individualized, up-to-date, and in compliance with the regulations set forth by CMS and IDPH.
The experienced nursing home abuse attorneys at the Noll Law Office are dedicated to fighting for residents’ rights in nursing homes. They can review the care plan and compare it to the care your family member actually received. In some instances, there isn’t a care plan at all! If your loved one has been the victim of neglect or abuse in a nursing home, contact the Noll Law Office at (217) 414-8889 for a FREE consultation today. They do not take a fee unless they obtain a settlement or jury verdict. They are experienced local lawyers who care about their clients and their families. The Noll Law Office: From the community. For the community.