Federal law requires that nursing homes develop care plans for all residents. A care plan, which can address both medical and nonmedical issues, outlines how the nursing home staff will help a resident, listing what each staff member will do and when it will happen. For example, a care plan might list that a nursing home resident needs to build strength and maintain muscle by walking a certain distance each day. A good care plan facilitates communication between nursing home staff and ensures that residents' needs are met. Someone unfamiliar with the resident should be able to pick up the nursing home care plan and know how to care for the resident.
Complete a comprehensive assessment of the resident's physical, social, emotional, and mental needs. Each nursing home may have a set of standard protocols to use when assessing a resident's needs.
Assemble a Care Plan Team that will work together to develop the Care Plan. The Care Plan Team may include nursing home staff, the resident's physician, the resident's family, and the resident.
Develop a list of the resident's problems. The problem list can include medical diagnoses, physical weaknesses, family problems, social withdrawal, and any other items affecting the resident's health and well-being.
For each problem listed, determine if it can get better with appropriate steps and action, is unlikely to improve but can be maintained, or is unlikely to improve and will probably continue to deteriorate.
For each problem that can be improved, develop specific, measurable, and attainable goals for improving the problem.
For each problem that can be maintained, develop specific, measurable, and attainable goals designed to keep the problem from getting worse or from developing complications.
For each problem that will probably continue to deteriorate, develop specific, measurable, and attainable goals that will delay or slow deterioration and that will provide the resident with optimal comfort and quality of life.
Develop interventions and plans for achieving each goal. The interventions and plans must incorporate physician orders, facility policies, and accepted standards of care. The resident and the resident's family may also provide input into the interventions and plans.
A facility should complete an initial nursing home care plan within 24 hours of a resident's admittance to the nursing home. A full care plan should be in place within 21 days. Both nursing home residents and their families can participate in meetings to develop and review nursing home care plans. Nursing home care plans need to be reviewed and modified as the resident's needs change, or at least every year.