ENSURING QUALITY CARE
CARE PLANNING PROCESS September 2019 Safety, Oversight and Quality Unit 1
PURPOSE AND KEY TERMS • Activities of daily living (ADL) The purpose is to assist the learner in understanding how to • Care plan develop an appropriate care plan • Narrative and incorporate resident choice • Hands-on assist/ Stand-by assist (person-centered planning) into the resident’s individualized care • Verbal cueing plan. • Reminiscence • Resident choice (person- centered planning) September 2019 Safety, Oversight and Quality Unit 2
OBJECTIVES The learner will be able to: Describe the components of a care plan Develop a care plan. Evaluate and implement resident choice in developing a care plan Demonstrate how to maximize resident independence Write a narrative September 2019 Safety, Oversight and Quality Unit 3
INTRODUCTION Narratives are time-consuming but offer a more complete record of your findings. There is no special form for narrating. Notebook paper is the most economical choice. All narratives must be dated and signed by the individual who wrote them. Writing narratives during the first 14 days of a residents admission helps to track what worked and what did not. Narratives also give you and the other caregivers a clear idea of what the resident can or cannot do and a record of how the individual is adjusting to the move. September 2019 Safety, Oversight and Quality Unit 4
INTRODUCTION CONTINUED Use this time to work with the resident to discuss choices, preferences and approaches in meeting their full range of physical, emotional, social and spiritual needs: • You must accurately identify areas where your services are needed and how you will provide them Once you are sure of what the resident can do and what others need to do to help them, note that information in the care plan. You are required to develop and maintain an accurate care plan for each resident. The AFH rules give specific requirements about care plans. See OAR 411-051-0115. September 2019 Safety, Oversight and Quality Unit 5
BASICS OF A CARE PLAN A care plan describes: • The resident’s needs and preferences • The resident’s capabilities and strengths • The assistance the resident requires for various tasks; and • By whom, when and how often the care will be provided The purpose of a care plan is to: • Encourage the resident to remain as independent as possible • Ensure consistency in care • Document the care needed and describe how the individual responds to that care • Provide evidence of the resident’s changing needs September 2019 Safety, Oversight and Quality Unit 6
BASICS OF A CARE PLAN CONTINUED The care plan must be kept in the individual’s resident records and must be available to: • All caregivers in the home • The resident • Division representatives • The state long-term care ombudsman • Other persons (such as the volunteer ombudsman, RNs, family,, etc.) with the permission of the resident or legal guardian September 2019 Safety, Oversight and Quality Unit 7
WRITING THE CARE PLAN The care plan describes how the resident’s needs are to be met: • Most of the information is already known to you or the resident • The care plan is a care agreement between you and the resident to ensure appropriate care is provided Important elements of care plan writing: • DO write the care plan within 14 days of a new resident’s admission • DO involve the resident as much as possible • DO make certain it is updated every six months or as the resident’s care needs change • DO make certain all caregivers are oriented to the resident’s needs September 2019 Safety, Oversight and Quality Unit 8
WRITING THE CARE PLAN CONTINUED Team members, such as the resident’s healthcare practitioner, home health, physical therapist and family members should be consulted if they are involved in the resident’s care. Make sure to note any specific tasks performed by these individuals. Detail the type of assistance needed and if any special equipment is used: • “Take to the bathroom every two hours during the day, once during the night (approximately 1:30am), provide stand-by assistance to adjust clothing. With verbal cueing the resident can perform other parts of the task independently.” September 2019 Safety, Oversight and Quality Unit 9
WRITING THE CARE PLAN CONTINUED Be specific about what needs to be done and who will perform the task, when they will do it, and how often it needs to be done. Regularly review and update care plans: • Plans must be reviewed, and appropriate changes noted, every six months or sooner if the resident’s needs change. The reviewer must date and sign the care plan. The document must be rewritten if the change makes the plan difficult to read or follow. September 2019 Safety, Oversight and Quality Unit 10
USE COMMON ACCEPTABLE TERMS Set-up: Getting things ready so the resident can perform an activity. • “Put toothpaste on the toothbrush so the resident can brush teeth; lay out clothes so the resident can get dressed; draw water in a basin and lay out a washcloth, soap and towel for the resident to give self a daily sponge bath.” Hands-on assistance: The caregiver physically performs all or parts of an activity because the resident is unable to do so. • “To help the resident get out of bed, verbally explain each step before proceeding. Lift behind head and, when holding under both knees, pivot the resident to a sitting position. Hold the elbow, count to three and say ‘stand.’ Guide to a standing position.” September 2019 Safety, Oversight and Quality Unit 11
USE COMMON ACCEPTABLE TERMS CONTINUED Stand-by assistance: A caregiver must be at the side of the resident and be ready to step in and take over the task should the resident be unable to complete the task independently. • “The resident is unsteady in his gait. A caregiver must stand-by the resident to steady him with a gait belt if it becomes necessary.” Verbal cueing: This term refers to giving reminders or directions to help the resident complete activities without hands-on assistance. • “The resident needs verbal cueing to get dressed in the morning. A caregiver must tell her what order to put her clothing on, and to remember to button, zip, tie, etc. to ensure it is properly fastened and in place.” September 2019 Safety, Oversight and Quality Unit 12
PARTS OF THE CARE PLAN The care plan provides important information about a resident’s: • Activities of daily living • Night needs • Medical needs • Social needs • Ability to exit in an emergency • Nursing delegations Entries on the care plan should be written to show the parts of the task the resident can perform independently as well as those the provider or caregivers need to help with. Some cognitive and/or emotional needs that result in challenging behaviors need to be addressed separately in the “Behavioral interventions” section of the care plan. September 2019 Safety, Oversight and Quality Unit 13
ACTIVITIES OF DAILY LIVING Bathing • Preferences for method of bathing (shower, bed bath, tub bath) and/or equipment needed such as bath bench, hand-held shower and grab bars • The day and time of the bath are important • Be sure to note any techniques used to make the bath easier for the caregiver and the resident • Note any behavioral support needs or special methods used to maintain dignity and privacy September 2019 Safety, Oversight and Quality Unit 14
ACTIVITIES OF DAILY LIVING CONTINUED Dressing • Explain the types of clothes the resident likes to wear and who chooses the clothes • List any methods that are used to encourage the resident to do as much as possible on their own • For example: “Lay out underwear, slacks and blouse on bed. Verbally cue her to get dressed. Put on her shoes and socks for her.” September 2019 Safety, Oversight and Quality Unit 15
ACTIVITIES OF DAILY LIVING CONTINUED Toileting • Note the frequency and pattern of bathroom use, the type of help needed, any incontinency needs, preventative measures, and sanitary supplies used • Include equipment helpful in toileting including elevated toilet seats, versa frame (grab bars on a frame on the toilet), and grab bars • Adding helpful pieces of equipment may help the resident to remain independent with toileting September 2019 Safety, Oversight and Quality Unit 16
ACTIVITIES OF DAILY LIVING CONTINUED Mobility and transfer • Describe the resident’s ability to get around with or without assistive devices • If they use a wheelchair or walker and do not need verbal cues or assistance the resident is considered independent in mobility • Any time the caregiver provides verbal cueing, stand-by assistance or hands- on assistance their role needs to be clearly explained • Any equipment used should be documented along with any pain, spasms, balance problems and the resident’s exercise and activity level September 2019 Safety, Oversight and Quality Unit 17
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