Care Plans and Preventing Avoidable Declines

Surveyors will investigate if the resident declined or failed to improve relative to expectations, and determine if this was avoidable or unavoidable.
The Care Plan is a record that describes the resident’s functional abilities at different times of the past year. Make sure the documentation is comprehensive and genuinely reflects the resident’s abilities. If the goals are realistic and regularly measured, it will help to identify declines.
Surveyors will focus on the Late-loss ADLs, those considered to be the last to decline or deteriorate: Bed Mobility, Transfer, Eating, and Toilet Use. They will use the Quality Indicators and the Quality Measures, and evaluate occurrences and preventative measures.
The Admission Assessment and Care Plan should accurately document the resident’s mobility, range of motion, transfer ability, and balance. Evaluations from Physical Therapy, Occupational Therapy, and Restorative Nursing will give in-depth information about the resident’s level of functioning.