Successful Care Plans
GuideOne Risk Resources for Health Care
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W. Des Moines, IA 50265-3538



Successful Care Plans

It is no surprise that one of the most closely reviewed documents in a nursing home is a resident's clinical record. In 2013, F-279 "Comprehensive Care Plans," was the fifth leading deficiency in the U.S., and a large focus of a formal study conducted by the Office of Inspector General in 2012. Poorly prepared care plans are not only exposing facilities to multiple survey deficiencies, they are used in civil lawsuits. Errors or inconsistencies in a care plan may bolster plaintiffs' claims of negligence or malpractice. Once jurors are shown examples of inaccuracy or incomplete care plans, it is likely they will believe all other allegations of poor quality of care.


The foundation of a good care plan begins with an assessment of the resident. In order to complete the comprehensive assessment, which helps with the building of the care plan, an interdisciplinary team (IDT) should be formed. That team, working alongside the attending physician, resident and the resident's family or legal representative, should develop a plan that includes measurable goals to help staff monitor the resident's progress, as well as ensure the implementation of resident-specific interventions to assist in achieving each goal. Remember, CNAs usually know the resident best, so if they find something that works well with a certain individual, they should share it with the rest of the IDT team.

Highest Functioning Level

An important part of the planning process is the development of a comprehensive care plan that seeks to assist the resident in achieving or maintaining the highest possible level of functioning. Based on the resident's admission assessment, clinical condition, disease processes and other information provided from the healthcare professionals and the resident, the facility must ensure that certain problems and high-risk conditions receive appropriate treatment and services to prevent development or worsening of these conditions. If the condition is clinically unavoidable, it should be documented by the physician as such.

Concise and Precise

Care plans must be thorough, yet brief enough to be useful. Those that are lengthy, difficult to read and are impractical, are the root cause of implementation issues. Care plans should be user-friendly and easy to read, trying best to avoid the use of difficult medical terminology that requires further research. Care plans also need to address key issues in a simple format.


Each resident's care plan should be unique to the individual. The document should not be an automated, computerized version with "canned problems, goals or approaches." A great deal of time may be required to develop the initial care plan, staff should be able to determine which resident's care plan they are reading without looking at the name on it.

Realistic and Achievable

An area commonly cited under F-279, relates to the importance of setting measurable goals to appropriate interventions. Goals must be achievable, but more importantly, they must reflect what is appropriate for a specific resident. If a goal cannot be measured, the progress a resident has made goes unnoticed. This also could cause the resident harm. Similarly, if an intervention is not appropriate, progress cannot be made.

When developing a care plan, strive to outline realistic goals. A realistic goal is one that the resident will be able to meet in a reasonable period of time. If the goals are not working, adapt them. Modify ineffective goals or approaches, as needed. Avoid leaving ineffective information in the care plan indefinitely.


This plan is a key document that should be kept up-to-date at all times. As changes and problems occur, even those considered minor, such as skin tear should be documented. Waiting until a quarterly assessment is due increases the resident's risk of complications, and thereby, the facility's legal exposure. Each time there is a change made on the care plan, proper legal documentation guidelines should be followed, including authenticating and dating the entry. This includes making a new entry, changing or discontinuing an entry.

When temporary or acute problems arise, the facility documents an assessment of the problem and implements a plan. The acute problem can be incorporated into the comprehensive care plan or can be documented on a separate acute/temporary care plan form. Constantly evaluate the care plan to ensure it is working. If an acute care plan is used, the problem, intervention(s) and resolution date should be documented.

If a resident experiences significant change in their condition and needs to have a new MDS completed, make sure the care plan is revised to meet the new level of care. After a hospitalization or a trip to the emergency room, update the resident's care plan, even if a significant change has not occurred. Review the reason why the resident was sent to the hospital.

During your quarterly care plan review, evaluate the resident's progress or decline. Determine if they have met or are making progress toward the goals listed. If the goal or intervention is futile, eliminate it. Then, modify the goals or interventions to be more realistic and achievable for the resident.

Key Components to Success

Supervision, coaching and communication are key components to ensuring your staff understand and deliver the resident care needs as best as possible. Staff must be held accountable for the care plan goals and interventions implemented. It is impossible to implement the care plan goals and interventions if the staff is not willing to or does not have the resources available.

Requiring staff members to use and update care plans daily creates an environment that meets the intent of the federal guidelines, provides the highest quality of care to the residents and protects the facility and staff members from potential liability exposure.

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