Nursing Home Care Plans and Why They Matter to a Legal Claim

Posted on behalf of Jeff Pitman on December 16, 2020 in Nursing Homes and Elder Rights
Updated on April 24, 2024

physician with an elderly coupleNursing home care plans play a major role in helping to ensure the overall well-being of a resident. What can you do when a facility fails in this duty and that neglect causes a loved one to suffer an injury, medical illness or even death?

Learn more about nursing home care plans below as PKSD Law explains what they are, why they may fail and why they are so important if you later have to pursue a legal claim.

What is a Care Plan?

Nursing homes are required to meet the quality-of-care standards defined at the federal level by both the Centers for Medicare and Medicaid (CMS) and the Nursing Home Reform Act (NHRA). However, what type of oversight is there to make sure this happens on a resident-by-resident basis?

This is the purpose of a properly written care plan. You can think of it as a strategy for meeting a resident’s daily and long-term needs, as well as a means to evaluate how well – or if – a facility is following that plan.

Care planning should be done with the input of a family member – or another who acts on behalf of the resident if no family member is available.

According to Medicare, a care plan should be based on a resident’s initial health assessment when he or she is admitted to a facility. A re-evaluation of this plan should happen at least every 90 days, or sooner if a resident’s needs require it.

Where Care Plans May Fail

Proof of neglect can be found not only in the process of creating a patient’s plan of care, but also in how it is – or is not- carried out by a nursing home or other long-term care facility. The general steps involved in a care plan are detailed below and should include:

Initial Assessment – Was it Adequate?

An initial assessment should happen when a resident is admitted. This evaluation should be both standardized and reproducible. What this means is that no matter which nurse or doctor does the assessment, the outcome should use the same tools and yield the same results.

If an assessment is not properly carried out, many of these common syndromes of the elderly could be missed:

  • Onset of dementia, Alzheimer’s or other mental health disorders
  • Pressure sores – including a resident’s risk for getting them
  • Urinary incontinence or repeating urinary tract infections
  • Risk of falling
  • Signs of depression
  • Functional decline
  • Overall frailty
  • Tendency to wander off
  • Malnutrition issues/failure to thrive

Creating the Plan of Care

A care plan is not created by adding a few scribbled notes to a patient’s chart. It is clearly written documentation that, in addition to the assessment for conditions described above, should also include:

  • A patient’s overall health risks
  • Future health goals
  • Specific steps or interventions required to meet those goals on a daily basis
  • Staff that will be needed to carry out each care task (nurses’ aide, nurse, physical therapist)

Additional Steps in the Process

Once a plan of care is created, a nursing home or long-term care facility must follow-up to make sure the plan is followed, which should include:

  • Proper communication to staff – The plan of care must be communicated to the appropriate staff daily and account for shift changes
  • Daily implementation – Proper compliance of a plan of care helps to avoid residents suffering medical conditions or injuries arising from errors or neglect
  • Reassessing and modifying –As stated above, this should happen quarterly or as needed, based on a resident’s changing health

Injuries That Can Happen

If a nursing home fails to follow a resident’s plan of care, injury, illness or death may occur. Some common results when a care plan is not followed may include:

  • Medication errors – or medication not given
  • Not following instructions for meals, such as feeding a resident or providing pureed food to help prevent choking
  • Reoccurring urinary tract infections which may be the result of hygiene neglect or failure to follow proper toileting procedures
  • Malnutrition or dehydration occurring from neglect
  • Failure to follow a defined turn schedule, causing the resident to suffer pressure sores

How a Care Plan Can Impact a Legal Claim

You may be able to use a care plan to help establish evidence for a nursing home case of neglect or abuse. However, this is a complex process that may benefit from the help of one of our Wisconsin nursing home abuse lawyers.

We may review the care plan for evidence, such as to determine if the initial assessment was inadequate, whether a formal plan of care was properly documented, if any additional reassessments happened and whether the plan was being properly and regularly followed.

An Experienced Attorney Matters in Nursing Home Cases

At PKSD, we have years of experience advocating for victims of nursing home abuse and neglect, and we have obtained millions in compensation for our clients. Our team of legal professionals are ready to help.

Not sure if you have a valid case? We offer a risk-free way to find out by providing an initial consultation at no cost to you. There is no obligation to hire our services, but you can get answers to your questions about the legal process. If we represent you, there is nothing to pay us until your case concludes, and we only get our attorney fees if we recover compensation for you.

PKSD Law. Experienced attorneys fighting for you. 414-333-3333

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