EMPOWEREDCAREGIVERS

PLAN:

The second letter of the “APIE” acronym is P for Plan. The nursing home has to have a comprehensive Interdisciplinary Care Plan with measurable objectives. In short, once the nursing home has assessed your loved one’s challenges and risks, they must take an interdisciplinary approach to care planning for these risks. Interdisciplinary means that all of the different disciplines of the nursing home should be involved such as nursing, attending physician, physical therapy, and social services.

Example: Mark is 76 years old when he is admitted to the nursing home for long term care. He was living with his son John but his advancing dementia was becoming too much for John and his wife (who both worked full time jobs) to handle. Mark has been falling and forgetting things. He cannot be left
home alone and he has several significant chronic medical conditions that require full time skilled nursing care. After a proper assessment of Mark which included the identification of diabetes, alzheimers, kidney problems, throat cancer, swallowing difficulties and significant behavioral issues related to underlying schizophrenia the nursing home sets down to care plan for Mark’s residency.

Unfortunately, the nursing home is understaffed and a single nurse prepares the entire care plan for Mark’s care. While she does develop specific interventions such as a wedge cushion and chair alarm to prevent Mark from falling, no one from dietary worked on the care plan. Unfortunately, the nurse is not savvy enough to recognize that the throat cancer and swallowing difficulties require a swallow study, speech therapy evaluation and dietary considerations. Had the dietician in the facility been involved in the care
plan she undoubtedly would have recommended a pureed diet to make sure that Mark did not choke as a result of his swallowing problems. Unfortunately, while the assessment was right on and the care plan was relatively comprehensive, this means very little when three days after admission Mark chokes to death on a sandwich that he never should have been eating had the proper discipline (ie. dietary) been involved in the care plan.

Upon completion a strong advocate will always request a full copy of the care plan. They will insist that all disciplines be involved in the care plan and they will review it themselves to make sure all issues are clearly addressed.

Also remember that the care plan must have measurable objectives. Here are some examples of measurable objectives:

“Mary will be in PT for ambulation 4 days a week. Mary will be on a toileting program and will be assisted to bathroom every two hours to prevent falls and maintain continence. Mary will ambulate 50 ft without
assistance in 6 weeks.”

“Mark will not develop any pressure ulcers on the sacrum in the next 6 weeks. This will be accomplished by repositioning Mark every two hours and documenting same on the skin flow sheet. Skin will be kept clean and dry and diaper will be changed every two hours.”.

“Mary will have no falls in the next thirty days. Mary will be encouraged to use call bell for assistance every shift. She will have a wedge cushion and a self releasing lap belt when in her wheelchair. She will have a bed alarm and a chair alarm on at all times. She will be assisted on a walk every morning and afternoon to spend pent up energy.”

“Mark will be fed at all meals and his weight will be monitored on a weekly basis. If he loses 3 pounds in any given month a dietary consult will be undertaken within 24 hours of the threshold weigh in.”

“Mary will gain 5 pounds in the next 8 weeks. She will be on strict meal monitoring. If she has two meals where she consumes less than 75% of her meal, protein shake will be added as a snack to prevent weight loss and promote nutrition.”

Here are some examples of non-measurable objectives that a “doop proof” advocate would question immediately:

“Mary will do better.”

“Mark will not get any worse”.

“Staff will monitor Mary.”

“Staff will attend to Mark’s needs.”

Overall objective - Don’t be afraid to ask to see the careplan when it is completed upon admission and after every amendment or re-admission. Also, always make sure to get a new copy following a care plan conference whether changes were implemented or not. Make sure that all of the areas you believe need to be addressed are in the care plan. If you see something missing, talk to the charge nurse or director of nursing if necessary to make sure the plan is amended. Don’t accept excuses like “well we will do that anyway, it doesn’t need to be in the careplan.” If its not in the careplan I want you to assume it is not being done.