Nursing Home Care Planning: The Nitty Gritty
Are you navigating the complexities of nursing home care planning? Understanding the details can make a world of difference in the quality of care your loved one receives. This process is crucial for ensuring that all medical, social, and personal needs are met comprehensively. In this week’s episode, nursing home abuse lawyer Rob Schenk discusses the intricacies of care planning in nursing homes with guest Ms. Amy Swinehart, diving into what families need to know to advocate effectively for their relatives.
SWINEHART:
In my experience, the care plans that are most effective are the ones where family is involved. Attend those meetings, they’re gonna go through every single care plan that is currently in place for that resident. Talk about things that are working, not working. You can bring it to the meeting, put the team on, notice that it’s a concern, and they can incorporate your concerns into the care plan.
SCHENK:
Hey, out there. Welcome back to the Nursing Home Abuse podcast, everybody. My name is Rob. I’ll be your host. Today we are talking all about the nitty gritty of the care plan. I think that we’ve covered, I. Like how care plans are made, why they’re made, what, what causes the care plan to change. But in this episode, I really wanna get down to brass tacks about how the care plan itself is, essentially trickles down to the staff like.
How the staff knows what’s on the care plan in order to do their job. Like literally the literally step by step how that gets communicated to the staffs. Like I, I’ve been wanting to have this conversation for a long time and I’m so happy that the individual that I’m having this conversation with is the.
Incredible. Amy Swinehart. She’s back again. I think this might be her fourth, maybe fourth or fifth appearance. Not sure, but we are definitely, she is the one to have this conversation with, so happy to do that with her.
Alright, now it’s time to get into the meat and potatoes of the episode. I want to introduce the fabulous Amy Swinehart.
Amy Swinehart’s journey in nursing home care started 20 years ago as a CNA while attending nursing school. Throughout college, she worked in various roles, including CNA, restorative aid and medication tech. Post graduation, she progressed from a floor nurse to director of nursing and nursing homes. Since 2018, Amy collaborates with.
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Attorneys nationwide, including myself, reviewing medical records, crafting work, product reports, and offering litigation support. Amy is my right arm for all of my merit reviews. I highly recommend her. She’s fantastic and we are so happy to have her on the show. Amy, welcome to the show.
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SWINEHART:
Thanks for having me again.
When are Care Plans required?
SCHENK:
I was thinking about how to ask the first question. I. And I was thinking about, I think it was Forrest Gump. There’s a scene where a little feather like is flying through the sky or maybe it’s a leaf. Do you know what I’m talking about? I think it’s at the end. No. No, like I think he’s sitting there and like he closes a book, or maybe it’s the box of chocolates and you follow the leaf or the feather.
SWINEHART:
Oh, okay.
SCHENK:
Maybe gene can like, I don’t know, in post-production, put that scene up as I’m talking about it, but like you, you notice and then it falls or what? I don’t even know what it is. I don’t even know what I’m talking about. Anyway, that’s the analogy that I wanted to make. In the worst roundabout way.
SWINEHART:
Yes.
SCHENK:
The life, the how A care plan flies through the air and ends up where it ends up. So that’s my terrible introductory windup question.
SWINEHART:
Okay. I’ve got a visualization. I got you. Yeah,
SCHENK:
I got you. Okay. I. So just imagine that the care plan has been written or typed or whatever, and then boom, where does it go? Forrest Gump? Like how does it get to where it goes?
SWINEHART:
Yeah. The care plan is initially developed once the facility is on notice that a risk of something exists. So whether it’s risk for falls or risk for aspiration, or risk for pressure ulcers, the care plan is triggered by an assessment that says, Hey, risk exists.
And so once the care plan exists, then it’s your, like you described, it’s a fluid thing. It’s something that kind of moves as the patient moves, something that should change as they change and always addressing what the patient’s current status is. What are they doing right now? What do they look like? Right now?
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How are Care Plans developed?
SCHENK:
The care plan reflects a risk. And an objective to get to, and the interventions needed to address that risk and get to that objective. I get that, but I guess what I’m envisioning as the feather is flying through the air, who is seeing it? Like literally, is it always on a computer screen?
Is it on a piece of paper? And if it’s and if so, like when is it looked at and who’s looking at it?
SWINEHART:
Sure. Yeah. So facilities are develop their own systems for how they wanna communicate care plan related details to the direct care staff. Depending on what the intervention is, depending on what the goal is, it may impact one discipline more than another.
So say if you have an a DL related care plan, say for ambulation. Station or transfers or something like that, then the information needs to get to the people who are ambulating and who are transferring. No, the staff does not have time to pull up every single care plan for every single resident on every single shift.
’cause we just said they, they’re fluid, they’re changing all of the time. So the facility needs to de develop a means for communicating to the direct care staff what things are going on the care plan, what things need to be implemented.
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How are Care Plans implemented?
SCHENK:
That’s great. So let’s do a, an intervention that would be, for example, turning and repositioning, which I guess Okay.
Would be traditionally done by CNA. So we have a risk of skin breakdown. The intervention is to turn and reposition the resident every two hours. That’s literally on the care plan, which is on a computer screen or on a piece of paper somewhere. But as you mentioned, how is that information provided to the CNAs and how do they know how often, who to do it to, all that kind of stuff.
SWINEHART:
Sure. So some facilities have a cardex that’s like an old fashioned way of describing it. It literally used to be a card that you would keep on a desk and it would have a, like a snapshot of the patient’s care. These days it’s electronic, so it’s actually in PCC for example, they have a cardex section of the electronic health record.
And when you’re entering things on the care plan, you can push things to the Cardex and the Cardex is a one page snapshot. So like in my last facility when I was at DON, we actually had a Cardex book. So after morning meeting, any changes we made to the care plan, any updates to the Cardex we would actually bring the Cardex book to morning meeting update what’s changed with that patient.
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And it stayed at the nurses station so that when the AIDS came on, they could look at everybody who was on their team. All of those card xs. And figure out what they need to do now. Now, that depends a lot on the patient the employee’s ability to remember the things that they read at the beginning of the shift.
I also think that it’s best practice to push those tasks onto the charting that you’re asking that employee to do. So if it’s a task for a CNA, then. The interventions that you expect them to carry out should be reflected in their documentation. When they go to chart that somebody ate breakfast, there should be something that prompts them, to have you turned and repositioned them, have you assisted them to the toilet, things like that.
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SCHENK:
So I guess what I’m hearing is that typically I. It’s not like the CNAs go from room to room and each room has the card deck and they look and go, okay, we’re gonna turn reposition Ms. Johnson. They do that. They go to the next room, and that card deck says, do this, and this. It seems that all of that information is relayed at the beginning of the shift and they just work and if they forget something, they just go back to the nurses station for that card exit.
Is that kind of how you’re is that what we’re saying?
SWINEHART:
Yeah. And a lot of times these aides have taken care of these patients before, and it’s not always that there’s a ton of changes happening every single day for one CNA who may have eight or 10 patients, only maybe one or two of their people may have had something changed.
So if they’re used to them, they know what they need. It’s not like they need to retain all of that information. But they do need to look at the Cardex to see if there’s anything new since the last time I took care of Mr. Jones. And then of course, the nurse is ultimately responsible for ensuring that anybody that they’re supervising is carrying out the tasks that they’re responsible for as well.
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SCHENK:
And that is for interventions that involve. The CNA. Let’s talk about the nurse. So let’s just say that now, let’s say that there’s a wound. Okay. So let’s say that there’s an intervention to follow, or maybe the intervention is actually change a bandage or whatever, or even follow the physician’s order, whatever the case is.
Okay. That the, in the information the nurse needs to know what to do is on that care plan. Is that also something that would be on a cardex or is the nurse pulling up the care plan and then going to, to the resident?
SWINEHART:
Yeah, usually the Cardex would be specific to, to aid related tasks. The nurses the most effective way to get something on a nurse’s radar is through the eMAR or the eTAR.
So they’re all shift, things are popping up on their screen, alerting them. It’s time for Mr. Jones’s, Tylenol, things like that. So I think that’s the most effective way to communicate to a nurse. If a nurse on Saturday afternoon is gonna need to remember to change that wound vac, the best way to do it is through the mar and the tar.
And then that’s. Where they can document that they did it, and it’s all in one place, then you don’t have to rely on them to go looking at the care plan or checking anything else. It’s all in, in one area.
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SCHENK:
So I guess and again, like this is why I love having you on, because I’m not a nurse. I’ve never been a nurse, but I guess in my mind, I’ve always made the assumption that maybe.
50 years ago, or 25 years ago, it wa the care plan was a document that you had in your pocket and you pulled it out anytime that you needed to know what was going on. But it’s not, it’s the care plan gets created and revise when it needs to. Okay. I understand that. But the information, the substance of it, filters out to the different parts of the chart or different documents.
For the actual care that needs to be done at this time, that it needs to be done. So like the care plan itself, when you’re drafted, you’re thinking about it holistically and it might say, here’s the treatment that you need to do. Here’s the intervention for the wound, or whatever. But no one’s looking at the care plan.
You’re looking at the tar if, if it right. Is that.
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SWINEHART:
I don’t say nobody’s looking at the care plan, somebody’s looking at the care plan, but it’s not practical for a nurse who may be responsible for, 20 patients on an evening shift. It’s not practical for them to review every care plan for every resident they’re responsible for.
Some of these residents have. 25 care plans, there’s just too much information. So yeah, it needs to be communicated in a different way. Some facilities have ways of doing alert charting or hot charting. So if it’s something that involves like a creation of a progress note, there would be an alert on a dashboard that says you need to do a skin assessment or you need to do a wound assessment or something.
And then for, and then that, then they would make like a note. I saw the wound. But then for other things that are just, you need to check off that you. Did it like maintain head of bed at 45 degrees or ensure heels are floating. The tar is, their whole shift, they’re working on checking off those tasks and completing things. So that’s the best way to, to communicate those things.
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SCHENK:
And that makes a lot of sense to me now in the sense that I’ve had a few cases, a few nursing home cases where I’ve deposed the nurse and I’ll be like, typically what’s on this care plan? They’ll be like, I have no idea. I don’t. I don’t ever look at a care plan.
I only look at X, Y, and Z. And that’s why it’s like the questions that I’m asking seem dumb, but that’s literally what I like. How do you like, I understand how we make the care plan. I get that. I’m just trying to understand how that information trickles down to the people that are actually doing it, and from what it sounds like it’s different ways, like it’s, it depending on the role, if it’s a CNA, the LPN or the RN and what the intervention is it’s gonna get Exactly. Yeah. That, that the intervention is gonna get trickled down in different ways, not necessarily. They’re not looking at the care plan document and doing something it’s little pieces. Wow.
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SWINEHART:
Yeah. And that’s why it’s so important because I hear a lot of times like, oh, attorney repositioning was on the care plan, or toileting was on the care plan, as if it exempts them from some sort of responsibility. And I’m like, it doesn’t stop there. It’s a process.
And there has to be evidence that the things that were on the care plan were actually done in real life. And in order for that to happen, the people who are putting their hands on the patient needs to know that the intervention exists.
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SCHENK:
You mentioned that at least in your experience when you were the DON.
The care plan was talked about for each resident at the beginning of the shift, and in any changes that need to be made, were made. How? How does that work? What is it in my mind, it’s kinda like when I waited tables and like we called it pre-shift and like it’s you got the head chef and he is like, all right, idiots.
This is like we have mashed potatoes and steak. Sell the fish because it’s going bad. Smile. Yeah. Be good. You know what I mean? So you’re like, okay, Ms. Johnson, last shift, she was belligerent or whatever. Keep an eye on this. And maybe I, is that kind of is it like that’s in my head that I’m envisioning?
SWINEHART:
Yeah, and I think there’s two things you’re talking about there. One, one, you’re talking about clinical startup. It’s a standard of care in nursing homes. It’s a meeting of the IDT members on a daily basis. Where they review all the orders that came in the day before. They read all the, this is what they should be doing.
Read all the progress notes on every resident for the day before, and then the team sits down and anybody that has any concerns, any recommendations. That’s when it all gets discussed. So if you read the progress notes and you find somebody is really depressed. Because their husband just passed away, social services is gonna see that note and say, okay, we need to look at their mental health care plan.
Does anybody know when the funeral is? And everybody can talk about how they’re going to help that resident through that issue. So that’s one thing that’s done on a daily basis, usually Monday through Friday. Some facilities have systems in place for like a manager on duty to go in on the weekend and do that kind of thing, but that’s the IDT responsibility with regards to the care plan.
Then shift to shift, the nurses are giving report and they’re going through every resident and they’re saying, Hey, he had a fall for me, or so-and-so’s on antibiotics for UTI and the nurses write down the things that are going on right now with the patients just from a shift to shift report.
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SCHENK:
I see.
So one is daily with the interdisciplinary team. And the other one is shift to shift with whoever the charge nurse or the head nurse is.
SWINEHART:
Exactly.
When are Care Plans revised?
SCHENK:
I see. Okay. All right, so I guess talking about the shift to shift change, right? So like we’re not talking about IDT, we’re not talking about the inter interdisciplinary team whose role primarily is to.
Assess the success of the care plan, right? And revise it if it needs to be, but shift to shift, like how does the nurse, that’s, between second and third shift is Hey, this happened. And how does that trigger the a, a revision of the care plan? What is the process typically with how whatever he or she puts in there, it goes to the IDT team or whatever.
Like what typically, how does that work?
SWINEHART:
So usually it’s done through the progress notes. Mr. Jones had a fall on my shift. I implemented a floor mat, and then the team the next day is gonna read that note and say, oh, Mr. Jones had a fall. They’re doing a floor mat for the time being. Is that a good intervention?
Then the team can say, oh no, their roommate is up and walking to the bathroom all the time. And that’s gonna create a hazard. We might need to change rooms or whatever it might be. So yeah, it’s usually through the progress note. Some facilities have a 24 hour report but it’s duplicative work.
Like you might as well just put it in the progress note and you kill two birds with one stone.
SCHENK:
Is any of this stuff I’m sure it has to be, but just Hey, listen, I didn’t have time to write it down. But this happened like that. That probably happens a lot, right?
SWINEHART:
Yeah. And between shifts, I think that, or I I remember I used to be a unit manager before I was a DON and I would come in on a Monday morning and there’d be all these notes under my door.
The Saturday night nurse was like, Hey, Mr. Jones is out of clothes. I didn’t have time to call the family or something like that. I. Kind of communicate things that way through a 24 hour report. The information can get disseminated in a lot of different ways, and it’s really the responsibility of each individual facility to find out which communication methods work the best for your team, given all the different personalities and the type of residents that you care for.
What systems are gonna work the most effectively for our team?
Why would a Care Plan need to be revised?
SCHENK:
So let’s do the example where Ms. Johnson had a fall. Okay. And typically in my cases I will see like an incident report, perhaps a like an sbar, some type of document that is more or less to describe an incident. Then sometimes I’ll have where there is some type of new assessment that’s triggered, right?
So the, whatever the fall risk assessment would be. ’cause maybe something has changed, how does that factor in, like typically, how does that affect the care plan at all? Or is it literally like you can skip those two steps? You can skip the incident report, you can skip the, theoretically the assessment if the care plan changes.
’cause the care plan is what drives the care. I guess you see what I’m saying? What, like what are the reasons why you would have an assessment or an incident report or not? I. If you’re gonna change the care plan anyway.
SWINEHART:
So I think with an incident report, in my experience, they usually include more details regarding the root cause analysis.
The report in the chart might say, Mr. Jones was found on the floor in his room. But the incident report is gonna tell you Mr. Jones tripped over his roommate’s walker because he left it in the middle of the walkway. So the incident report usually has a little bit more details about the circumstances of the incident, and if it was unwitnessed or the circumstances are unknown, it’s usually a collection of witness statements and things like that.
But the standard of care does require assessments to be done anytime there’s a question as whether or not the care plan is effective. Because the care plan is. Triggered by an assessment. When you get to the point where you’re questioning whether or not your care plan works, you have to wonder if your assessment that started all of it may be not accurate any longer.
And so that’s why usually if there’s a fall incident, it will trigger a fall assessment. Risk assessment.
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SCHENK:
Yeah, because I guess I asked that because oftentimes in my cases, there’ll be a revision of the care plan, but I can’t find a corresponding assessment that goes with it. How do we arrive at this being the intervention that it best addresses whatever the change of condition was.
All right. So we’ve talked all about how the facility staff understands what is expected of them, vis-a-vis the care plan, but. What is the family’s role in the creation and execution of the care plan?
SWINEHART:
That is such a good question because. In my experience, the care plans that are most effective are the ones where family is involved.
Family can offer you information that you may not know about a resident. So the best way for families to do that really would be just to go to those quarterly care plan meetings. You’re probably getting an invitation from a social worker at the facility, maybe the unit manager. We’re doing Mr.
Jones’s care conference this month. Attend those meetings. They’re gonna go through every single care plan. That is currently in place for that resident. Talk about things that are working, not working. If you as a family member have observed, maybe on Friday nights it seems like the dinner is always late or something like that, you can bring it to the meeting, put the team on notice that it’s a concern.
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They can incorporate your concerns into the care plan. I can think of one occasion where we had a resident who was being very difficult overnight. And we just could not get to the bottom of why this person didn’t wanna sleep. There was so many behaviors overnight. Family came in and did the care conference and explained to us that he worked the night shift.
It never crossed our mind. So we were able to develop a care plan around, this night shift kind of mentality. Create activities throughout the night so that it was no longer a fight. We weren’t forcing him to comply with all the day shift people who go to sleep at eight o’clock.
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SCHENK:
Well said Amy again you’re becoming like the, you’re like almost essentially an honorary cohost of the show, so I really appreciate every time you come on, I learn all kinds of new things, but thank you so much for sharing your knowledge with us
SWINEHART:
Thanks for having me.
SCHENK:
You’re welcome. Appreciate it. Folks. I hope that you found this episode educational.
I know that I did. New episodes of the Nursing Home Abuse podcast come out every single Monday, wherever you get your podcasts from. But you can also watch them too. Some of the episodes are more visual. So for example, we had Matthew Mooney on maybe last episode or a few episodes ago, where we looked at nursing home complaints.
And so you would benefit by watching that particular episode, but. Consume it however you want. I’m not, there’s no, no judgment on this side of the camera. If you have a suggestion for a topic that you would like for me to cover, please let me know. If you have an idea for a guest that you would like for me to talk to, let me know that as well.
Enjoyed having you. Thank you so much as always for consuming this podcast. And with that. We’ll see you next time.
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