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Care Planning / Care Reviews
A Care Plan is an agreed-upon set of goals for the resident, with actions and assigned responsibilities and timelines for working towards the goals. Many goals for residents in long term care facilities are "maintenance" goals or "comfort" goals and as such are ongoing.  However, there are many instances when an acute problem can be resolved, for example if the resident has recently had a fractured hip, there will be very specific rehabilitative goals, with set outcomes and timelines.

On the day of admission, the RN and RPN of the resident's unit will speak with the resident and/or resident's family members to gather information about the resident's immediate nursing needs.  Basic vitals will be taken (BP, temperature, height, etc.) and an assessment of the resident's abilities in terms of their abilities regarding "activities of daily living" (ADLs) will be done.  Medications will be entered into our system and our pharmacy informed of the medications that the resident is taking. Initial assessment regarding dietary requirements will also be done immediately.  The result of these assessments will be an initial plan of care that will guide the staff in the first few days.

Within the first week, the resident will meet with the assigned physician for an initial physical and history.

Over the next few weeks, staff from other disciplines (Spiritual & Religious Care, Volunteer Services, Therapeutic Recreation, Housekeeping & Laundry, Maintenance) will introduce themselves to the new resident to discuss the resident's needs and concerns.

A Care Review will be scheduled with the new resident and family and the interdisciplinary team approximately 4-6 weeks following admission to ensure that the resident's needs are being met and to discuss areas of concern.  All of the information gathered, from the professional disciplines and from the resident and family, is put together into an overall "Care Plan".

Care Reviews are scheduled annually after the "Admission Care Review" and are intended for the same purpose: to ensure that all is going well, that the resident's goals are being achieved, that nothing is being missed.

A year is a long time between Care Reviews however; it is important to know that every quarter, the doctor, nurse and pharmacist meet to evaluate the care and the medications the resident is receiving.  The nurse writes a quarterly summary of the resident's status at that time.  As well, each resident's condition is monitored on a daily basis.  If there is something that is particularly troubling of an ongoing nature, a "Special Needs Care Review" can be convened for a resident at any time