THE RESIDENT ASSESSMENT AND PLAN OF CARE
by Roberta Mikles
Nursing homes are required to conduct an assessment on every individual admitted. The assessment is initiated on the day of admission. The law requires that a comprehensive assessment be completed within 14 days of admission. (7 days for Medicare payment purposes).
This assessment includes information gathered from the resident (if possible), family members, physician and any one else who can provide information. A comprehensive assessment can take numerous days to complete, keeping in mind, the facility staff will be observing the resident during the assessment period. Also included is an assessment of the physical abilities/limitations of the resident and information regarding his/her medical condition. This gathered information is analyzed and a written plan of care is developed. This written document, in the resident's medical record, will provide "all" information necessary to anyone who is giving direct care to the resident. The care plan will address the concerns and needs of the resident. The care plan will describe how the staff will assist the resident on a daily basis.
Staff should be well familiar with each resident's care plan for who they are providing care. If not, beware!!!! This is how mistakes, injuries and accidents happen. Note: It is ok, and your right to ask if the person providing care is acquainted with the care plan and if he/she has a working knowledge of what is written. In other words, not knowing specifics to the resident, i.e. number of staff needed to transfer a resident, what type of diet, what consistency of food (liquid/solid/soft), does the resident need to be turned in bed , etc. can be cause for gross negative outcomes, including death.
This sounds a bit overstated, however, in my experience I have seen residents who have fallen out of bed and the end result was death. The resident was able to get out of bed alone and walk to the bathroom. However, the side rails were up on the bed. The resident called for help. The staff did not respond within a reasonable amount of time. The resident climbed over the side rails, rather than urinating in the bed. Fell and had severe injuries and died. The care plan will state if the resident needs side rails or not. (Side rails can be hazardous and each individual must be individually evaluated.)
Another example is a staff feeding a resident liquid (glass of water) when, in fact, the resident was on a special diet (thickened liquids) due to a swallowing problem. As a result, the resident, choked and was taken to the emergency room, aspirated and died.
I give these two examples to impress upon you the importance of staff knowing what is written on the care plan. CNAs often do not get to read the care plans (for many reasons). It is then up to the charge nurse (RN or LVN) to provide all the information. I repeat, staff not familiar with the resident's care plan, for who they are providing care, should "not" be providing care. This is dangerous.
THE RESIDENT ASSESSMENT AND PLAN OF CAREby Roberta Mikles
This assessment includes information gathered from the resident (if possible), family members, physician and any one else who can provide information. A comprehensive assessment can take numerous days to complete, keeping in mind, the facility staff will be observing the resident during the assessment period. Also included is an assessment of the physical abilities/limitations of the resident and information regarding his/her medical condition. This gathered information is analyzed and a written plan of care is developed. This written document, in the resident's medical record, will provide "all" information necessary to anyone who is giving direct care to the resident. The care plan will address the concerns and needs of the resident. The care plan will describe how the staff will assist the resident on a daily basis.
Staff should be well familiar with each resident's care plan for who they are providing care. If not, beware!!!! This is how mistakes, injuries and accidents happen. Note: It is ok, and your right to ask if the person providing care is acquainted with the care plan and if he/she has a working knowledge of what is written. In other words, not knowing specifics to the resident, i.e. number of staff needed to transfer a resident, what type of diet, what consistency of food (liquid/solid/soft), does the resident need to be turned in bed , etc. can be cause for gross negative outcomes, including death.
This sounds a bit overstated, however, in my experience I have seen residents who have fallen out of bed and the end result was death. The resident was able to get out of bed alone and walk to the bathroom. However, the side rails were up on the bed. The resident called for help. The staff did not respond within a reasonable amount of time. The resident climbed over the side rails, rather than urinating in the bed. Fell and had severe injuries and died. The care plan will state if the resident needs side rails or not. (Side rails can be hazardous and each individual must be individually evaluated.)
Another example is a staff feeding a resident liquid (glass of water) when, in fact, the resident was on a special diet (thickened liquids) due to a swallowing problem. As a result, the resident, choked and was taken to the emergency room, aspirated and died.
I give these two examples to impress upon you the importance of staff knowing what is written on the care plan. CNAs often do not get to read the care plans (for many reasons). It is then up to the charge nurse (RN or LVN) to provide all the information. I repeat, staff not familiar with the resident's care plan, for who they are providing care, should "not" be providing care. This is dangerous.
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