The initial care plan
Essentially, the care plan is a roadmap for daily care. Input from the resident and their family or legal representative is crucial, and the care plan should be easy to understand. All caregivers should be informed of the care plan’s preferences to ensure these goals are met.
Federal law requires the initial care plan to be prepared within 14 days of a resident’s admission to a nursing home. Both the resident and their family are entitled to copies of the original care plan and any updates. Each care plan should be personalized, reflecting the resident’s specific goals and care needs:
• Plans for maintaining or improving mobility
• Preferred bed times and wake times
• Dietary restrictions
• Current medications and known medication allergies
• Preferred bathing and meal times
• Needs for repositioning to avoid bed sores
• Fall risks
• Hobbies.
Care conferences
The resident is the “driver” of her or his own health care, goals, and daily schedule. A care conference allows the resident and their family to discuss any care issues with the administration and staff, addressing deviations from the current care plan and suggesting solutions. Care conferences are usually scheduled every three months after the initial care plan is established following the admission. They can be held more frequently, however, if needed. Ideally, the facility’s social worker will schedule these meetings. Participants should include:
• The resident
• The director of nursing
• The social worker
• The STNAs who provide routine care
• The resident’s family members or legal representative. It’s good practice for everyone attending to have copies of the current care plan. The conference should be scheduled based on the availability of the resident and their family. If a family member cannot attend in person, the facility should arrange for phone or online participation. The meeting should not be rushed, and staff should listen carefully and respond clearly.
Long-Term-Care Ombudsmen regularly visit nursing homes and assisted-living facilities throughout Ohio. Staff and volunteers inform residents of their rights, resolve complaints, provide community contact, and empower residents to advocate for themselves. For more information about receiving services or becoming a certified volunteer, please call 419-259-2891 or 1-800542-1874.
Cheryl Zimmerman is a Long-Term-Care-Ombudsman Associate. ✲
